Passing a smoke-free law in a pro-tobacco culture: a multiple streams approach

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.

Opening windows and closing gaps: a case analysis of Canada's 2009 tobacco additives ban and its policy lessons

BACKGROUND

In 2009, Canada adopted legislation (Bill C-32) restricting the sale of flavoured tobacco products, one of the first in the world. This study examines the agenda-setting process leading to the adoption of Bill C-32.

METHODS

This research was conducted using a case study design informed by Kingdon's Multiple Streams framework and Heclo's policy learning approach. In-depth interviews were conducted with key informants from government, health-based non-governmental organizations (NGOs), trade associations and the cigar manufacturing sector (n = 11). Public documents produced by media (n = 19), government (n = 11), NGOs (n = 15), as well as technical reports (n = 8) and formal stakeholder submissions (n = 137) were included for analysis. Data were coded with the objective of understanding key events or moments in the lead up to the adoption of Bill C-32 and the actors and arguments in support of and opposition to Bill C-32.

RESULTS

The findings point to the importance of a small but active group of NGOs who worked to publicize the issue and eventually take advantage of an open policy window. Our analysis also illustrates that even though consensus was developed about the policy problem and civil society was able to garner political support to address the problem, disagreement and dissent pertaining to the technical dimensions of the policy solution created loopholes for the tobacco industry to exploit.

CONCLUSIONS

NGOs remain a critical factor in efforts to strengthen tobacco control policy. These organizations were able to mobilize support for the tobacco flavouring ban adopted at the Federal level in Canada, and although the initial Bill had major limitations to achieving the health objectives, the persistence of these NGOs resulted in amendments to close these loopholes.

Variations in support for secondhand smoke restrictions across diverse rural regions of the United States

Significant disparities exist between rural-urban U.S.

POPULATIONS

Besides higher smoking rates, rural Americans are less likely to be protected from SHS. Few studies focus across all regions, obscuring regional-level differences. This study compares support for SHS restrictions across all HHS regions.

DATA

2014/15 TUS-CPS; respondents (n = 228,967): 47,805 were rural residents and 181,162 urban. We examined bi-variates across regions and urban-rural adjusted odds ratios within each. Smoking inside the home was assessed along with attitudes toward smoking in bars, casinos, playgrounds, cars, and cars with kids. Urban respondents were significantly more supportive of all SHS policies: (e.g. smoking in bars [57.9% vs. 51.4%]; support for kids in cars [94.8% vs. 92.5%]. Greatest difference between urban-rural residents was in Mid-Atlantic (bar restrictions) and Southeast (home bans): almost 10% less supportive. Logistic regression confirmed rural residents least likely, overall, to support SHS in homes (OR = 0.78, 95% CI 0.74, 0.81); in cars (OR = 0.87, 95% CI 0.79, 0.95), on playgrounds (OR = 0.88, 95% CI.83, 0.94) and in bars OR = 0.88, 95% CI 0.85, 0.92), when controlling for demographics and smoking status. South Central rural residents were significantly less likely to support SHS policies-home bans, smoking in cars with kids, on playgrounds, in bars and casinos; while Heartland rural residents were significantly more supportive of policies restricting smoking in cars, cars with kids and on playgrounds. Southeast and South Central had lowest policy score with no comprehensive state-level SHS policies. Understanding differences is important to target interventions to reduce exposure to SHS and related health disparities.

The passage of tobacco control law 174 in Lebanon: reflections on the problem, policies and politics

Progress in tobacco control policy making has occurred worldwide through advocacy campaigns involving multiple players- civil society groups, activists, academics, media and policymakers. The Framework Convention on Tobacco Control (FCTC)-the first ever global health treaty-outlines evidence-based tobacco control policies. Lebanon ratified the FCTC in 2005, but until 2011, tobacco control policies remained rudimentary and not evidence-based. Beginning in 2009, a concerted advocacy campaign was undertaken by a variety of stakeholders with the aim of accelerating the process of adopting a strong tobacco control policy. The campaign was successful, and Law 174 passed the Lebanese Parliament in August 2011. In this article, we analyse the policy making process that led to the adoption of Law 174 using Kingdon's model. The analysis relies on primary and secondary data sources including historical records of key governmental decisions, documentation of the activities of the concerted advocacy campaign and in-depth interviews with key stakeholders. We describe the opening of a window of opportunity as a result of the alignment of the problem, policy and politics streams. Furthermore, findings revealed that despite the challenge of persistent tobacco industry interference and established power relations between the industry, its allies and policymakers; policy entrepreneurs succeeded in supporting the alignment of the streams, and influencing the passage of the law. Kingdon's multiple stream approach was useful in explaining how tobacco control became an emerging policy issue at the front of the policy agenda in Lebanon.

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.

Key Factors Inhibiting Legislative Progress Toward Smoke-Free Coverage in Appalachia

The Appalachian Region has among the highest rates of smoking and smoking-related illness in the United States. Strong smoke-free legislation could help protect nonsmoking residents from the harmful effects of secondhand smoke. However, there is a dearth of state, county, city, and subcounty smoke-free law coverage throughout Appalachia. As of July 2016, only 21% of Appalachian residents were covered by comprehensive smoke-free laws (i.e., 100% coverage for workplaces, restaurants, and bars). Only 46% of Appalachians lived in places with 100% smoke-free workplace laws, only 30% lived in places with 100% smoke-free restaurant laws, and only 29% lived in places with 100% smoke-free bar laws. Reasons for this lack of smoke-free law coverage include socioeconomic disadvantage, the historical importance of tobacco in Appalachian economies, and preemptive state legislation. By understanding the contextual issues that have inhibited smoke-free legislation, smoke-free advocates will be better prepared to lead efforts that expand smoke-free coverage in this region.

Why and How Political Science Can Contribute to Public Health? Proposals for Collaborative Research Avenues

Written by a group of political science researchers, this commentary focuses on the contributions of political science to public health and proposes research avenues to increase those contributions. Despite progress, the links between researchers from these two fields develop only slowly. Divergences between the approach of political science to public policy and the expectations that public health can have about the role of political science, are often seen as an obstacle to collaboration between experts in these two areas. Thus, promising and practical research avenues are proposed along with strategies to strengthen and develop them. Considering the interdisciplinary and intersectoral nature of population health, it is important to create a critical mass of researchers interested in the health of populations and in healthy public policy that can thrive working at the junction of political science and public health.

A Multiple Streams analysis of the decisions to fund gender-neutral HPV vaccination in Canada

In Canada, the human papillomavirus (HPV) vaccine is licensed and recommended for females and males. Although all Canadian jurisdictions fund school-based HPV vaccine programs for girls, only six jurisdictions fund school-based HPV vaccination for boys. The research aimed to analyze the factors that underpin government decisions to fund HPV vaccine for boys using a theoretical policy model, Kingdon's Multiple Streams framework. This approach assesses policy development by examining three concurrent, but independent, streams that guide analysis: Problem Stream, Policy Stream, and Politics Stream. Analysis from the Problem Stream highlights that males are affected by HPV-related diseases and are involved in transmitting HPV infection to their sexual partners. Policy Stream analysis makes clear that while the inclusion of males in HPV vaccine programs is suitable, equitable, and acceptable; there is debate regarding cost-effectiveness. Politics Stream analysis identifies the perspectives of six different stakeholder groups and highlights the contribution of government officials at the provincial and territorial level. Kingdon's Multiple Streams framework helps clarify the opportunities and barriers for HPV vaccine policy change. This analysis identified that the interpretation of cost-effectiveness models and advocacy of stakeholders such as citizen-advocates and HPV-affected politicians have been particularly important in galvanizing policy change.

A Policy Analysis of Smoke-Free Legislation in Kentucky

This article presents a policy analysis of proposed smoke-free legislation in Kentucky during the 2015 General Assembly. Kingdon's three streams model of agenda setting is used to analyze the failure to pass HB145. Secondhand smoke exposure and related deaths are a significant public health problem in Kentucky, a state with one of the highest smoking rates in the U.S. HB145, a comprehensive smoke-free bill, was designed to protect workers and the general public from secondhand smoke and e-cigarette aerosol in enclosed workplaces and public places, with few exemptions. The bill faced intense criticism from opponents who were concerned about violation of personal and business rights and the belief that the decision should be addressed on a local level. HB145 passed the House with amendments but failed to receive a hearing in the Senate. Failure of the smoke-free legislation was due to partisanship, fragmentation of advocacy groups, lack of political bargaining, and conflict of values. As in past years, the policy window did not open for state smoke-free legislation in 2015.

Tobacco-control policies in tobacco-growing states: where tobacco was king

POLICY POINTS: The tobacco companies prioritized blocking tobacco-control policies in tobacco-growing states and partnered with tobacco farmers to oppose tobacco-control policies. The 1998 Master Settlement Agreement, which settled state litigation against the cigarette companies, the 2004 tobacco-quota buyout, and the companies' increasing use of foreign tobacco led to a rift between the companies and tobacco farmers. In 2003, the first comprehensive smoke-free local law was passed in a major tobacco-growing state, and there has been steady progress in the region since then. Health advocates should educate the public and policymakers on the changing reality in tobacco-growing states, notably the major reduction in the volume of tobacco produced.

CONTEXT

The 5 major tobacco-growing states (Kentucky, North Carolina, South Carolina, Tennessee, and Virginia) are disproportionately affected by the tobacco epidemic, with higher rates of smoking and smoking-induced disease. These states also have fewer smoke-free laws and lower tobacco taxes, 2 evidence-based policies that reduce tobacco use. Historically, the tobacco farmers and hospitality associations allied with the tobacco companies to oppose these policies.

METHODS

This research is based on 5 detailed case studies of these states, which included key informant interviews, previously secret tobacco industry documents (available at http://legacy.library.ucsf.edu), and media articles. This was supplemented with additional tobacco document and media searches specifically for this article.

FINDINGS

The tobacco companies were particularly concerned about blocking tobacco-control policies in the tobacco-growing states by promoting a pro-tobacco culture, beginning in the late 1960s. Nevertheless, since 2003, there has been rapid progress in the tobacco-growing states' passage of smoke-free laws. This progress came after the alliance between the tobacco companies and the tobacco farmers fractured and hospitality organizations stopped opposing smoke-free laws. In addition, infrastructure built by National Cancer Institute research projects (COMMIT and ASSIST) led to long-standing tobacco-control coalitions that capitalized on these changes. Although tobacco production has dramatically fallen in these states, pro-tobacco sentiment still hinders tobacco-control policies in the major tobacco-growing states.

CONCLUSIONS

The environment has changed in the tobacco-growing states, following a fracture of the alliance between the tobacco companies and their former allies (tobacco growers and hospitality organizations). To continue this progress, health advocates should educate the public and policymakers on the changing reality in the tobacco-growing states, notably the great reduction in the number of tobacco farmers as well as in the volume of tobacco produced.

Smoke-free policy implementation: theoretical and practical considerations

Secondhand smoke exposure is a major public health issue, increasing the risk of cardiovascular and respiratory diseases and cancer. Although best practices for adopting smoke-free policy are well understood, there is limited research on the effective implementation of smoke-free policy. This article presents theoretical and practical considerations for smoke-free policy implementation in three Kentucky communities guided by the Institutional Analysis and Development (IAD) Framework. Although both Danville and Lexington-Fayette County, Kentucky have comprehensive smoke-free policies, Danville had more effective implementation, as well as better outcomes. Further study is needed to understand the critical elements of smoke-free policy implementation and their association with population outcomes. The IAD is a promising model to guide the study of both policy adoption and implementation.

Multiple streams approach to tobacco control policymaking in a tobacco-growing state

Smokefree policies (SFPs) have diffused throughout the US and worldwide. However, the development of SFPs in the difficult policy environment of tobacco-producing states and economies worldwide has not been well-explored. In 2007, Tennessee, the third largest tobacco producer in the US, enacted the Non-Smoker Protection Act (NSPA). This study utilizes the multiple streams model to provide understanding of why and how this policy was developed by triangulating interviews with key stakeholders and legislative debates with archival documents. In June 2006, the Governor unexpectedly announced support for SFP, which created a window of opportunity for policy change. The Campaign for Healthy and Responsible Tennessee, a health coalition, seized this opportunity and worked with the administration and the Tennessee Restaurant Association to negotiate a comprehensive SFP, however, a weaker bill was used by the legislative leadership to develop the NSPA. Although the Governor and the Tennessee Restaurant Association's support generated an environment for 100% SFP, health groups did not fully capitalize on this environmental change and settled for a weak policy with several exemptions. This study suggests the importance for proponents of policy change to understand changes in their environment and be willing and able to capitalize on these changes.

Fewer hospitalizations for chronic obstructive pulmonary disease in communities with smoke-free public policies

OBJECTIVES

We determined the impact of smoke-free municipal public policies on hospitalizations for chronic obstructive pulmonary disease (COPD).

METHODS

We conducted a secondary analysis of hospital discharges with a primary diagnosis of COPD in Kentucky between July 1, 2003, and June 30, 2011 using Poisson regression. We compared the hospitalization rates of regions with and without smoke-free laws, adjusting for personal and population covariates, seasonality, secular trends over time, and geographic region.

RESULTS

Controlling for covariates such as sex, age, length of stay, race/ethnicity, education, income, and urban-rural status, among others, we found that those living in a community with a comprehensive smoke-free law or regulation were 22% less likely to experience hospitalizations for COPD than those living in a community with a moderate-weak law or no law. Those living in a community with an established law were 21% less likely to be hospitalized for COPD than those with newer laws or no laws.

CONCLUSIONS

Strong smoke-free public policies may provide protection against COPD hospitalizations, particularly after 12 months, with the potential to save lives and decrease health care costs.

Child sexual abuse prevention policy: an analysis of Erin's law

Child sexual abuse affects thousands of children in the United States and is vastly underreported. Tertiary prevention policies, primarily in the form of sex offender registries and community notification programs, have received the most attention and funding. Few policies have focused on school-based prevention. One recently passed law in Illinois mandates all K-5 public schools to implement sexual abuse prevention programs. The law was championed by a young social worker, Erin Merryn. Through the multiple streams framework, this article examines the unique set of political circumstances, united with Merryn's advocacy, which created the opportunity for the law to pass.

The pattern of indoor smoking restriction law transitions, 1970-2009: laws are sticky

OBJECTIVES

We examined the pattern of the passage of smoking laws across venues (government and private workplaces, restaurants, bars) and by strength (no law to 100% smoke-free).

METHODS

We conducted transition analyses of local and state smoking restrictions passed between 1970 and 2009, with data from the Americans for Nonsmokers' Rights Ordinance Database.

RESULTS

Each decade, more laws were enacted, from 18 passed in the 1970s to 3172 in the first decade of this century, when 91% of existing state laws were passed. Most laws passed took states and localities from no law to some level of smoking restriction, and most new local (77%; 5148/6648) and state (73%; 115/158) laws passed in the study period did not change strength.

CONCLUSIONS

Because these laws are "sticky"-once a law has passed, strength of the law and venues covered do not change often-policymakers and advocates should focus on passing strong laws the first time, rather than settling for less comprehensive laws with the hope of improving them in the future.

Readiness for smoke-free policy and overall strength of tobacco control in rural tobacco-growing communities

Rural, tobacco-growing areas are disproportionately affected by tobacco use, secondhand smoke, and weak policies. The study determined whether overall strength of Resources, Capacity, and Efforts in tobacco control predicts readiness for smoke-free policy in rural communities, controlling for county population size and pounds of tobacco produced. This was a correlational, cross-sectional analysis of data from key informants (n = 148) and elected officials (n = 83) from 30 rural counties who participated in telephone interviews examining smoke-free policy. Six dimensions of community readiness (knowledge, leadership, resources, community climate, existing smoke-free policies, and political climate) were identified and summed to assess overall readiness for smoke-free policy. General strength of overall Resources, Capacity and Efforts in tobacco control at the county level was measured. Readiness for smoke-free policy was lower in communities with higher smoking rates, higher tobacco production, and smaller population. Efforts related to general tobacco control (i.e., media advocacy, training, and technical assistance) predicted readiness for local smoke-free policy development (standardized β = .35, p = .05), controlling for county population size and pounds of tobacco produced. Given that small, rural tobacco-growing communities are least ready for smoke-free policy change, tailoring and testing culturally sensitive approaches that account for this tobacco-growing heritage are warranted.

Secular trends and smoke-free policy development in rural Kentucky

Secondhand smoke (SHS) exposure causes cardiovascular disease, lung cancer and pulmonary disorders. Smoke-free policies are the most effective way to prevent exposure to SHS. A 5-year community-based randomized control trial (RCT) is in progress to assess factors associated with smoke-free policy development in rural communities. Considering secular trends is critical when conducting community-based RCTs as they may threaten the internal validity of the study. For the purposes of this paper, secular trends are defined as patterns or recurring events that are not directly related to smoke-free policy but have the potential to influence policy development. There are no established protocols to monitor secular trends in the study of smoke-free policy in rural communities. The purpose of this paper is to (i) describe the development of a protocol to identify and monitor secular trends that may threaten the internal validity of a community-based RCT to promote smoke-free policy development and (ii) describe secular trends identified in the first 2 years of the RCT. The sample includes 854 secular events captured from media outlets covering the 40 study counties over the first 2 years of the RCT. Of these 854 events, there were 281 secular events in Year 1 and 573 in Year 2. This paper focuses on five specific categories: 'tobacco use and cessation activities', 'farming', 'economics', 'city/county infrastructure' and 'wellness'. This protocol is a feasible yet time-intensive method of identifying events that may threaten the internal validity of a community-based RCT.

The changing role of agriculture in tobacco control policymaking: a South Carolina case study

To document the behavior of tobacco manufacturers' agricultural third-party allies in South Carolina from the 1970s through 2009, we analyzed news reports, public documents and internal tobacco industry documents and conducted interviews with knowledgeable individuals. We found that agriculture-based interest groups (the Farm Bureau), elected state agency heads (Commissioners of Agriculture) and tobacco-area legislators acted as an iron triangle containing strong third-party allies of tobacco manufacturers from the 1970s through the 1990 s. The Farm Bureau and Commissioners of Agriculture reacted to national-level changes in the tobacco leaf market structure by shifting towards a neutral position on tobacco control, while some tobacco-area legislators remained manufacturer allies (Sullivan, Barnes, & Glantz, 2009). This shift was reinforced by public health outreach and successes, which were in turn facilitated by the lack of opposition from agricultural groups. We conclude that public health advocates in tobacco-growing states should use the pragmatic shift of agricultural groups' position to challenge remaining third-party manufacturer alliances and agriculture-based opposition to tobacco control policies.

Clean indoor air ordinance coverage in the Appalachian region of the United States

OBJECTIVES

We sought to quantitatively examine the pattern of, and socioeconomic factors associated with, adoption of clean indoor air ordinances in Appalachia.

METHODS

We collected and reviewed clean indoor air ordinances in Appalachian communities in 6 states and rated the ordinances for completeness of coverage in workplaces, restaurants, and bars. Additionally, we computed a strength score to measure coverage in 7 locations. We fit mixed-effects models to determine whether the presence of a comprehensive ordinance and the ordinance strength were related to community socioeconomic disadvantage.

RESULTS

Of the 332 communities included in the analysis, fewer than 20% had adopted a comprehensive workplace, restaurant, or bar ordinance. Most ordinances were weak, achieving on average only 43% of the total possible points. Communities with a higher unemployment rate were less likely and those with a higher education level were more likely to have a strong ordinance.

CONCLUSIONS

The majority of residents in these communities are not protected from secondhand smoke. Efforts to pass strong statewide clean indoor air laws should take priority over local initiatives in these states.

But will I be re-elected? What happens to local level policy makers who support clean indoor air laws?

This research was conducted to determine the impact of voting for clean indoor air ordinance on a local-level policy maker's re-election status. Secondary data were used to identify local tobacco ordinances in Arizona proposed between 2001 and 2005, score ordinance content for comprehensiveness, identify policy makers who voted and how they voted, and determine if the measure passed or failed. Participation in and outcomes of subsequent elections were documented from public records. Ninety-two local-level policy makers in 15 local jurisdictions considered clean indoor air laws between 2001 and 2005. Policy makers who voted for these ordinances were more likely to be re-elected than those who voted against them. Structured interviews revealed that policy makers did not believe the issue had an impact on re-election results and believed that although the issue may have been contentious, it was no longer salient in the community.

Public opinion and smoke-free laws

Public support for Lexington-Fayette County, Kentucky's smoke-free law, perception of health risks from exposure to secondhand smoke (SHS), smoking behaviors, and frequency of visiting restaurants, bars, and entertainment venues were assessed pre- and post-law. Two cohorts of noninstitutionalized adults (N = 2,146) were randomly selected and invited to participate in a 10- to 15-min telephone survey. Public support for the smoke-free law increased from 56% to 63%, and respondents were 1.3 times more likely to perceive SHS exposure as a health risk after the law took effect. Although adult smoking and home smoking policy did not change post-law, adults frequented public venues at least as much as before the law. Lexington adults favored the smoke-free legislation despite living in a traditionally protobacco climate. The smoke-free law acted as a public health intervention as it increased perception of risk of heart disease and cancer from SHS exposure.