Policy makers' perspectives on tobacco control advocates' roles in regulation development

Awareness of tobacco industry tactics among tobacco control communities in Thailand and its association with attitudes towards tobacco industry and perceptions of e-cigarettes

BACKGROUND

Tobacco industry denormalisation is a key strategy recommended by the WHO Framework Convention on Tobacco Control as it is associated with reducing smoking behaviours and positively influencing public and policymakers' opinion towards tobacco control. However, studies of awareness of tobacco industry tactics among public health players and policymakers in low-income and middle-income countries are limited.

METHODS

We conducted an online survey of individuals who had been involved in tobacco control in Thailand. Multivariate ordinal logistic regression analysis was used to determine the association between awareness of tobacco industry tactics and different attitudes towards tobacco industry and perceptions towards e-cigarettes, controlling for role in tobacco control and demographics among 441 respondents.

RESULTS

Of the respondents, 11.3% had never heard of any tobacco industry tactics, whereas 11.1% had heard of all tactics asked in the survey. Tobacco industry tactics which were less known by participants were intimidation (30.6%) and illicit trade (37.4%). Participants who were more aware of tobacco industry tactics were more likely to have negative attitudes towards the tobacco industry and e-cigarettes. Compared with active experts of the Provincial Tobacco Products Control Committee and provincial public health officials who work in tobacco control programmes, advocates who worked for civil society organisations in tobacco control were more aware of tobacco industry tactics and had less favourable perceptions of e-cigarettes.

CONCLUSION

This study emphasises the importance of educating public health professionals and policymakers about tobacco industry behaviour, especially in the era of e-cigarettes.

Advocacy for Global Tobacco Control and Child Health

Tobacco and secondhand smoke remain leading threats to public health. Evidence since the 1950s has shown that the tobacco industry has acted in bad faith to deceive the public about the health effects of smoking. They have specifically targeted vulnerable populations including children and adolescents with various-and often misleading-marketing efforts and promotions. The increased popularity and weak regulation of electronic cigarettes have created a new generation of smokers who mistakenly believe they are "safer" from harm. Continued research, advocacy, and government action are needed to protect public health. Public health advocates must know the evidence, build coalitions, and prepare for industry countermeasures. Persistence is key, but public health efforts have successfully decreased tobacco-related deaths.

'You cannot touch taxes easily': making the case for tobacco taxation in India

India represents over 1.3 billion people with >100 million adult smokers. The catastrophic health costs of smoking are staggering; and estimates show that even modest increases in taxes on cigarettes and bidis would both raise substantial revenues for the government and save ∼69 million years of healthy life over the next four decades. Karnataka represents a good example of tobacco control efforts and their impact. This case study examines the factors that have contributed to tobacco control policy in Karnataka based on 23 semi-structured interviews with key informants engaged in tobacco policymaking and decision-making, tobacco control/taxation research and advocacy. Their narratives indicate that: (i) Domestic taxation policy is complicated by the complex tax structure and centralized control over taxation with the introduction of Goods and Services Tax; (ii) Implementation of legal frameworks is a challenge, due to conflicts with powerful industry and farmer lobbies. A vigorous civil society backed by the Courts is necessary to garner political support; (iii) Action on taxation is hampered by weak leadership and mixed messaging; and (iv) There is a need for innovative policy solutions to promote both demand- and supply-side measures for tobacco control. Tobacco control advocates need to recognize the political economy of tobacco control and generate strong, reliable and scientifically sound evidence to support their arguments. Working for incremental 'wins' in terms of more stringent application of existing legal frameworks can make a substantial difference even in contexts where enhancing tobacco taxes is a challenge. Promoting multisectoral action is critical, at both policy and the ground levels, by expanding ownership and responsibility for tobacco control to sectors beyond health. Finally, the health sector needs to recommit to its role as a champion for tobacco control. Failure to do so would amount to a failure on multiple fronts-public health, economic, fiscal and ethical.

Setting the policy agenda for graphic health warning labels: An analysis of online news media coverage in South Korea, 2016

INTRODUCTION

In South Korea, a bill requesting the implementation of graphic health warning labels (GHWLs) on tobacco products was adopted at the Assembly Plenary Session on 29 May 2015, and the law was implemented on 23 December 2016. During the period, a plan of the technical details of GHWLs, such as the making of graphic warnings, was examined by the Regulatory Reform Committee (RRC). This study aims to investigate what the media reported over that period and whether the RRC's policy decisions changed.

METHODS

We conducted a content analysis of online media reports from the first legislative examination (22 April 2016) to the re-examination (13 May 2016). We coded 150 news reports according to two types (news and opinions) and three slants in terms of being in favor of or opposed to the initially government's implementation plan of GHWLs: positive, negative, and neutral.

RESULTS

At the first legislative examination, some committee members recommended placing pictorial warnings at the bottom of a cigarette pack as opposed to the plan. Initially, the media reported the results of the committee decisions neutrally. However, over time, positive news and opinions on tobacco control policy and support for positioning the GHWLs at the top of packages increased before the committee carried out the re-examination. Only 15 (10.0%) news reports adopted a negative slant, while the reports with positive (n=101; 67.3%) and neutral slants (n=34; 22.7%) comprised the majority. At the re-examination, the committee withdrew their earlier recommendation to position the GHWLs at the bottom of cigarette packs, finally deciding that the pictorial warnings should be located at the top of the packs, as per the original government's plan.

CONCLUSIONS

The friendly media coverage of the tobacco control policy suggests that the media would be a major factor in the policymakers' decision. Because the media play an important role in defining social issues in the policy-decision process, garnering support from the media is important in the tobacco control legislative process.

Analysis of the legislative process related to the implementation of graphic health warning labels on tobacco products in South Korea

INTRODUCTION

Well-designed health warnings on tobacco packaging enhance cost-effectively public awareness of the risks of using tobacco products. However, many countries have experienced difficulties in implementing pictorial warnings. The purpose of this study is to present the topics that arose during the legislative process that preceded implementation of graphic health warning labels (GHWLs) on tobacco products in South Korea, and discuss the outcomes.

METHODS

We used qualitative content analysis to analyze lawmakers' statements, and those of committee members in meetings that preceded the drafting of the legislative document pertaining to GHWLs in South Korea.

RESULTS

In discussions surrounding the adoption of the GHWLs, the main point of contention was the level of disgust induced by pictorial warnings. When discussing how warnings should be inscribed on packaging after adoption of GHWLs, lawmakers disagreed regarding the physical position of the warnings. Because of continuous objections raised by some lawmakers, implementation of GHWLs was delayed, and, when actually introduced, the warnings were toned down. Some lawmakers communicated with tobacco companies; thus the companies participated in the legislative process in South Korea.

CONCLUSIONS

To prevent tobacco companies from negatively influencing tobacco control efforts, it is essential that all communications with such companies be publicly disclosed and that the tobacco industry be prohibited from contacting lawmakers involved in the legislative process of tobacco control.

Use of Comparative Case Study Methodology for US Public Health Policy Analysis: A Review

CONTEXT

There is growing recognition that policies influence population health, highlighting the need for evidence to inform future policy development and reform.

OBJECTIVES

This review describes how comparative case study methodology has been applied to public health policy research and discusses the methodology's potential to contribute to this evidence.

METHODS

English-language, peer-reviewed articles published between 1995 and 2012 were sought from 4 databases. Articles were included if they described comparative case studies addressing US public health policy. Two researchers independently assessed the 20 articles meeting review criteria.

MAIN OUTCOME MEASURES

Case-related characteristics and research design tactics utilized to minimize threats to reliability and validity, such as the use of multiple sources of evidence and a case study protocol, were extracted from each article.

RESULTS

Although comparative case study methodology has been used to analyze a range of public health policies at all stages and levels, articles reported an average use of only 3.65 (out of 10) research design tactics.

CONCLUSION

By expanding the use of accepted research design tactics, public health policy researchers can contribute to expanding the evidence needed to advance health-promoting policies.

'It will harm business and increase illicit trade': an evaluation of the relevance, quality and transparency of evidence submitted by transnational tobacco companies to the UK consultation on standardised packaging 2012

INTRODUCTION

Transnational tobacco companies (TTCs) submitted evidence to the 2012 UK Consultation on standardised packaging (SP) to argue the policy will have detrimental economic impacts and increase illicit tobacco trade.

METHODS

A content analysis of the four TTC submissions to the consultation assessed the relevance and quality of evidence TTCs cited to support their arguments. Investigative research was used to determine whether the cited evidence was industry connected. Fisher's exact tests were used to compare the relevance and quality of industry-connected and independent from the industry evidence. The extent to which TTCs disclosed financial conflicts of interest (COI) when citing evidence was examined.

RESULTS

We obtained 74 pieces of TTC-cited evidence. The quality of the evidence was poor. TTCs cited no independent, peer-reviewed evidence that supported their arguments. Nearly half of the evidence was industry-connected (47%, 35/74). None of this industry-connected evidence was published in peer-reviewed journals (0/35) and 66% (23/35) of it was opinion only. Industry-connected evidence was of significantly poorer quality than independent evidence (p<0.001). COIs were not disclosed by TTCs in 91% (32/35) of cases.

CONCLUSIONS

In the absence of peer-reviewed research to support their arguments, TTCs relied on evidence they commissioned and the opinions of TTC-connected third-parties. Such connections were not disclosed by TTCs when citing this evidence and were time consuming to uncover. In line with Article 5.3 of the Framework Convention on Tobacco Control and broader transparency initiatives, TTCs should be required to disclose their funding of all third-parties and any COIs when citing evidence.

"Entrenched practices and other biases": unpacking the historical, economic, professional, and social resistance to de-implementation

BACKGROUND

In their article on "Evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices," Prasad and Ioannidis (IS 9:1, 2014) referred to extra-scientific "entrenched practices and other biases" that hinder evidence-based de-implementation.

DISCUSSION

Using the case example of the de-implementation of radical mastectomy, we disaggregated "entrenched practices and other biases" and analyzed the historical, economic, professional, and social forces that presented resistance to de-implementation. We found that these extra-scientific factors operated to sustain a commitment to radical mastectomy, even after the evidence slated the procedure for de-implementation, because the factors holding radical mastectomy in place were beyond the control of individual clinicians. We propose to expand de-implementation theory through the inclusion of extra-scientific factors. If the outcome to which we aim is appropriate and timely de-implementation, social scientific analysis will illuminate the context within which the healthcare practitioner practices and, in doing so, facilitate de-implementation by pointing to avenues that lead to systems change. The implications of our analysis lead us to contend that intervening in the broader context in which clinicians work--the social, political, and economic realms--rather than focusing on healthcare professionals' behavior, may indeed be a fruitful approach to effect change.

"Hearing from all sides" How legislative testimony influences state level policy-makers in the United States

BACKGROUND

This paper investigates whether state legislators find testimony influential, to what extent testimony influences policy-makers' decisions, and defines the features of testimony important in affecting policy-makers' decisions.

METHODS

We used a mixed method approach to analyze responses from 862 state-level legislators in the United States (U.S.). Data were collected via a phone survey from January-October, 2012. Qualitative data were analyzed using a general inductive approach and codes were designed to capture the most prevalent themes. Descriptive statistics and cross tabulations were also completed on thematic and demographic data to identify additional themes.

RESULTS

Most legislators, regardless of political party and other common demographics, find testimony influential, albeit with various definitions of influence. While legislators reported that testimony influenced their awareness or encouraged them to take action like conducting additional research, only 6% reported that testimony changes their vote. Among those legislators who found testimony influential, characteristics of the presenter (e.g., credibility, knowledge of the subject) were the most important aspects of testimony. Legislators also noted several characteristics of testimony content as important, including use of credible, unbiased information and data.

CONCLUSION

Findings from this study can be used by health advocates, researchers, and individuals to fine tune the delivery of materials and messages to influence policy-makers during legislative testimony. Increasing the likelihood that information from scholars will be used by policy-makers may lead to the adoption of more health policies that are informed by scientific and practice-based evidence.

Bridging the gap between science and public health: taking advantage of tobacco control experience in Brazil to inform policies to counter risk factors for non-communicable diseases

AIMS AND DESIGN

The historical and economic involvement of Brazil with tobacco, as a major producer and exporter, was considered an insurmountable obstacle to controlling the consumption of this product. Nevertheless, the country was able to achieve significant progress in implementing public policies and to take an international leadership position, meeting its constitutional commitment to protect public health. In this paper we provide a brief historical overview of tobacco control (TC) in Brazil, and analyse the factors that contributed to the major decline in tobacco consumption in the country over the last 20 years, as well as identify the challenges that had to be overcome and those still at play.

FINDINGS

The Brazilian case demonstrates how cross-sectorial collaborations among health-related groups that capitalize on their respective strengths and capacities can help to influence public policy and overcome industry and population resistance to change. Although Brazil still lags behind some leading TC nations, the country has an extensive collaborative TC network that was built over time and continues to focus upon this issue.

CONCLUSIONS

The tobacco experience can serve as an example for other fields, such as alcoholic beverages, of how networks can be formed to influence the legislative process and the development of public policies. Brazilian statistics show that problems related to non-communicable diseases are a pressing public health issue, and advocacy groups, policy-makers and government departments can benefit from tobacco control history to fashion their own strategies.

Tobacco control interest groups and their influence on parliamentary committees in Canada

OBJECTIVES

The aim of this study was to determine how tobacco control interest groups influence tobacco policy decision-making through submissions and presentations to parliamentary committees.

METHODS

A qualitative content analysis was used to examine the presentations and submissions on tobacco-related legislation made to parliamentary committees between 1996 and 2004. The sample was identified from the public list of tobacco-related bills tabled in both the House of Commons and the Senate; the Government of Canada website and LEGISinfo were used to determine which committee reviewed the relevant bill. Committee clerks were asked to send submissions and presentations related to specific bills identified through LEGISinfo. Submissions and presentations were scanned and entered into QSR N6 software for coding. The coding instrument was adapted from previous studies employing qualitative content analysis. Montini and Bero's recommendations were used to evaluate the submissions and presentations.

RESULTS

Tobacco control interest groups did present scientific evidence to support tobacco control. However, they underused credible witnesses to present information at meetings. The topics presented by tobacco control interests groups were usually relevant to the bill being discussed.

DISCUSSION

Tobacco control interest groups employed some of the strategies suggested by Montini and Bero in their attempt to influence parliamentary committees through submissions and presentations. They did include scientific evidence in their submissions; however, they could improve their strategies in the area of using credible witnesses, such as scientists and medical experts. Incorporating Montini and Bero's recommendations into lobbying efforts may increase success in influencing committees.

Evidence and argument in policymaking: development of workplace smoking legislation

Background

We sought to identify factors that affect the passage of public health legislation by examining the use of arguments, particularly arguments presenting research evidence, in legislative debates regarding workplace smoking restrictions.

Methods

We conducted a case-study based content analysis of legislative materials used in the development of six state workplace smoking laws, including written and spoken testimony and the text of proposed and passed bills and amendments. We coded testimony given before legislators for arguments used, and identified the institutional affiliations of presenters and their position on the legislation. We compared patterns in the arguments made in testimony to the relative strength of each state's final legislation.

Results

Greater discussion of scientific evidence within testimony given was associated with the passage of workplace smoking legislation that provided greater protection for public health, regardless of whether supporters outnumbered opponents or vice versa.

Conclusion

Our findings suggest that an emphasis on scientific discourse, relative to other arguments made in legislative testimony, might help produce political outcomes that favor public health.

The role of public participation in public health initiatives: an analysis of the WHO Framework Convention on Tobacco Control

This is a content analysis of 489 written documents and 142 hearing testimonies, submitted to the World Health Organisation (WHO), regarding the Framework Convention on Tobacco Control (FCTC) during the comment period of 2000. Our aim was to consider the benefits and limitations of inviting public participation. We found that, overall, those who offered commentary were in support of the FCTC and any ensuing treaty, especially if it protected children. The minority who opposed the treaty argued that restrictions on tobacco trade would further damage the economies of poor nations that are financially dependent upon tobacco. The FCTC that was adopted at the World Health Assembly in May 2003 addressed many of the concerns raised by the public in written commentary and hearing testimony: children and youth; advertising and sponsorship; tobacco product labelling; second-hand smoke; taxes; smuggling; liability; tobacco product regulation; and the involvement of non-government organisations (NGOs). We conclude that the benefits of public participation in public health policy formation are numerous, including levelling the playing field for public health activists and NGOs, building the expertise of advocates that can be generalised to other public health efforts, giving the political process legitimacy and credibility, as well as coalition building and grassroots momentum.

Smokefree environments in Latin America: on the road to real change?

Latin American countries are experiencing an increasing burden of tobacco-related diseases. Smoke free policies are cost-effective interventions to control both exposure of nonsmokers to the toxic chemicals in secondhand tobacco smoke and to reduce the prevalence of smoking and its consequent morbidity and mortality. The World Health Organization Framework Convention on Tobacco Control has created momentum in Latin America to implement meaningful tobacco control policies. As of August 2007, Uruguay, two provinces and three cities in Argentina, and one state in Venezuela, had passed, regulated, and enforced 100% smokefree legislation. The tobacco industry, working through local subsidiaries, has been the strongest obstacle in achieving this goal and has prevented progress elsewhere in the region. During the 1990s, transnational tobacco companies Philip Morris International and British American Tobacco developed voluntary initiatives ("Courtesy of Choice" and "Environmental Tobacco Smoke Consultancy" programs) to prevent effective smokefree policies. Another important barrier in the region has often been a weak and fragmented local civil society. Opportunities in the region that should be taken into account are a high public support for smokefree environments and increasing capacity building available from international collaboration on tobacco control. Policymakers and tobacco control advocates should prioritize the implementation of smokefree policies in Latin America to protect nonsmokers, reduce smoking prevalence with its economic and disease burden in the region.

Participation and argument in legislative debate on statewide smoking restrictions

Background

In this paper we review the relationship between participation in legislative hearings, the use of ideological arguments, and the strength of public health legislation using a theoretical construct proposed by E. E. Schattschneider in 1960. Schattschneider argued that the breadth and types of participation in a political discussion could change political outcomes.

Methods

We test Schattschneider's argument empirically by reviewing the efforts of six states to pass Clean Indoor Air Acts by coding testimony given before legislators, comparing these findings to the different characteristics of each state's political process and the ultimate strength of each state's legislation.

Results

We find that although greater participation is associated with stronger legislation, there is no clear relationship between the use and type of ideological arguments and eventual outcomes.

Conclusion

These findings offer validation of a long-standing theory about the importance of political participation, and suggest strategies for public health advocates seeking to establish new legislation.

A pilot qualitative study of New Zealand policymakers' knowledge of, and attitudes to, the tobacco industry

BACKGROUND

The actions of policymakers are critical to advancing tobacco control. To evaluate the feasibility of using anonymous in-depth interviews to ascertain policymakers' knowledge about, and attitudes to, the tobacco industry, we undertook a pilot study involving New Zealand policymakers.

METHODS

Five politicians (from different political parties) and five senior officials, who were involved in tobacco control policy, were recruited for semi-structured, anonymous, face-to-face interviews.

RESULTS

Recruitment of appropriate senior policymakers was found to be possible. Interviewees were willing to answer questions fully and frankly about their knowledge and views of the tobacco industry.The preliminary data from this pilot suggest that some New Zealand politicians appeared to see contact with the industry as similar to contact with other groups, whereas the officials indicated at least a different style of relationship. Only one politician knew if their party accepted funding from tobacco companies. All but one of the interviewees thought that promotion of tobacco to under-16 s still occurs, albeit indirectly. The interviewees' knowledge of the investment in tobacco industries by New Zealand government agencies was low or absent.While most of those interviewed showed scepticism about tobacco company public relations efforts, this was absent in some cases. There was a wide understanding that the tobacco industry will use many tactics in the pursuit of profit, and to counteract government efforts to reduce the harm from smoking.

CONCLUSION

In-depth anonymous interviews appear to be feasible and can be productive for exploring sensitive tobacco-related policy issues with policymakers. The preliminary data from this group of New Zealand policymakers suggest important knowledge gaps, but also general distrust of this industry. From a tobacco control perspective, the results may suggest a greater focus by advocates on the funding of political parties by the tobacco industry, and on government agency investment in the tobacco industry.

Purchasing health insurance coverage for smoking cessation treatment: Employers describe the most influential information in this decision

Employer provision of insurance coverage for smoking cessation treatment (SCT) remains spotty despite a body of treatment efficacy and cost-effectiveness evidence available to inform and support this health care purchasing decision. This qualitative study examined the information on which this coverage decision is made. In this study, state employers describe the content and sources of the most influential information in their decision to provide insurance coverage for SCT as well as a second health benefit for comparative purposes. We provide insight into the extent to which SCT evidence informs the SCT coverage decision and suggest topics and targets for research dissemination. We interviewed 55 employee benefit staff in 35 states. Responses were compared from states with and without SCT coverage to explore the types of information that may be more effective at promoting coverage. The content and sources of the information employers judged most useful varied notably between states with and without SCT coverage. Compelling evidence of the efficacy of SCT and its cost-effectiveness did not appear to play an influential role in the SCT decision among states without SCT coverage relative to states with SCT coverage. States with SCT coverage relied significantly on benefit consultants and actuaries for the information they described as most influential; in comparison, noncovered states reported service providers, staff, and the Internet as major information sources. To foster employers' provision of SCT coverage, research dissemination efforts should emphasize SCT efficacy and cost-effectiveness information and tailor communication to benefit consultants and actuaries in addition to employers themselves.

Predictors of support for environmental tobacco smoke bans in state government

BACKGROUND

Environmental tobacco smoke (ETS) is a major threat to public health, associated with a number of serious diseases, and a leading cause of death. Previous research demonstrates that enactment of government policies mandating clean indoor air is effective in creating more smoke-free public places and decreasing the incidence of smoking. Both researchers and community activists have an interest in understanding the factors that predict support for the regulation of ETS.

METHODS

This study examined predictors of support for regulating ETS by surveying 684 city and county public officials in Colorado who were interviewed by phone and mail (response rate 61%).

RESULTS

Thirty-five percent of public officials reported that it is a "serious" or "very serious" problem that nonsmokers breathe in other people's cigarette smoke, 21% were "neutral," and 42% said that it was "not serious" or "not serious at all." Results indicated that support for policies to control ETS and promote clean indoor air is significantly more prevalent among public officials who: (1) believe that tobacco use is a serious problem in their community, (2) believe that breathing environmental tobacco smoke is a serious problem for nonsmokers, (3) believe that city and county government should get involved with people's decisions about smoking, (4) support smoking-cessation programs for public employees, and (5) have smoked less than 100 cigarettes during their lifetime.

CONCLUSIONS

Both the harms of ETS and legislation to create smoke-free environments remain controversial among local officials. Smoke-free advocates should support officials who believe that ETS is a problem and persuade officials on the harms of ETS and the need for government intervention.

British Columbia capital regional district 100% smokefree bylaw: a successful public health campaign despite industry opposition

OBJECTIVE

To describe how the British Columbia Capital Regional District successfully passed, implemented, and enforced a 100% smokefree bylaw in all public places, including restaurants and bars, despite an aggressive campaign by the tobacco industry (acting through the hospitality industry) to stop it.

METHODS

Information was obtained from news reports, internal tobacco industry documents, reports, public documents, and interviews with key players. Tobacco industry documents were accessed between February and April 2002. This project was approved by the University of California San Francisco committee on human research.

RESULTS

As in the USA and elsewhere in the world, the tobacco industry in British Columbia, Canada, recruited and created hospitality associations to fight against the district smokefree bylaw. They used the classic industry rhetoric of individual rights and freedoms, economic devastation, and ventilation as a solution. Public health authorities were able to counter industry strategies with a strong education campaign, well written bylaws, and persistent enforcement.

CONCLUSION

It is possible to overcome serious opposition orchestrated by the tobacco industry and develop and implement a 100% smokefree bylaw in Canada. Doing so requires attention to detail in drafting the bylaw, as well as a public education campaign on the health dangers of secondhand smoke and active enforcement to overcome organised resistance to the bylaw. Jurisdictions considering smokefree bylaws should anticipate this opposition when developing and implementing their bylaws.

Tobacco industry efforts to defeat the occupational safety and health administration indoor air quality rule

OBJECTIVES

We describe tobacco industry strategies to defeat the Occupational Safety and Health Administration (OSHA) Indoor Air Quality rule and the implementation of those strategies.

METHODS

We analyzed tobacco industry documents, public commentary on, and media coverage of the OSHA rule.

RESULTS

The tobacco industry had 5 strategies: (1) maintain scientific debate about the basis of the rule, (2) delay deliberation on the rule, (3) redefine the scope of the rule, (4) recruit and assist labor and business organizations in opposing the rule, and (5) increase media coverage of the tobacco industry position. The tobacco industry successfully implemented all 5 strategies.

CONCLUSIONS

Our findings suggest that regulatory authorities must take into account the source, motivation, and validity of arguments used in the regulatory process in order to make accurately informed decisions.

Review of the quality of studies on the economic effects of smoke-free policies on the hospitality industry

OBJECTIVE

To compare the quality and funding source of studies concluding a negative economic impact of smoke-free policies in the hospitality industry to studies concluding no such negative impact.

DATA SOURCES

Researchers sought all studies produced before 31 August 2002. Articles published in scientific journals were located with Medline, Science Citation Index, Social Sciences Citation Index, Current Contents, PsychInfo, Econlit, and Healthstar. Unpublished studies were located from tobacco company websites and through internet searches.

STUDY SELECTION

97 studies that made statements about economic impact were included. 93% of the studies located met the selection criteria as determined by consensus between multiple reviewers.

DATA EXTRACTION

Findings and characteristics of studies (apart from funding source) were classified independently by two researchers. A third assessor blind to both the objective of the present study and to funding source also classified each study.

DATA SYNTHESIS

In studies concluding a negative impact, the odds of using a subjective outcome measure was 4.0 times (95% confidence interval (CI) 1.4 to 9.6; p = 0.007) and the odds of not being peer reviewed was 20 times (95% CI 2.6 to 166.7; p = 0.004) that of studies concluding no such negative impact. All of the studies concluding a negative impact were supported by the tobacco industry. 94% of the tobacco industry supported studies concluded a negative economic impact compared to none of the non-industry supported studies.

CONCLUSION

All of the best designed studies report no impact or a positive impact of smoke-free restaurant and bar laws on sales or employment. Policymakers can act to protect workers and patrons from the toxins in secondhand smoke confident in rejecting industry claims that there will be an adverse economic impact.

Framing processes in public commentary on US federal tobacco control regulation

Governmental health policy officials increasingly seek to promote public participation in expert and technical decisions regarding health regulation. The issues of what rôle the public plays in regulatory processes, and how health policy officials orient to public opinion, matter especially in the US context, where public commentary is a requisite component of federal rule-making. This paper examines written commentary as one specific, institutionalized form of public participation. To understand the relationship between scientific evidence and public commentary in public health regulation, we examine a US Food and Drug Administration (FDA) regulation, proposed in 1995, to restrict the promotion and sale of tobacco products to minors. We use recent work on collective action frames to analyse how the FDA framed the proposed regulation as a rational, science-based policy; the discursive practices employed in the public commentary either to embrace or to contest the FDA's framing; and how the agency presented the final version of its rule as responsive to that public commentary. Our content analyses reveal a significant disparity between the FDA's emphasis on scientific evidence and the commentators' emphases on political and ideological frames, which we analyse in terms of counter-framing. An orientation to the dynamics of framing and counter-framing contributes to an understanding of the relationship between scientific evidence and public commentary in the formulation of controversial health policy regulations.

ASHRAE Standard 62: tobacco industry's influence over national ventilation standards

OBJECTIVE

To describe the role of the tobacco industry in the development of ventilation standards for indoor air quality by influencing the American Society of Heating, Refrigeration, and Air Conditioning Engineers (ASHRAE).

METHODS

Review of tobacco industry documents available on the internet between January 2001 and March 2002. Search terms included "ASHRAE", "ventilation", "minutes", "memo", and the names of key players and organisations as identified in the initial searches. Analysis of ASHRAE and other relevant documents publicly available and the personal files of a Standard 62 committee member; interviews of a selected number of ASHRAE players; observation of an ASHRAE meeting.

RESULTS

The tobacco industry has been involved in the development of ventilation standards for over 20 years. It has successfully influenced the standard and continues to attempt to change the standard from a smoke-free framework into an "accommodation" framework. The industry acts directly and through consultants and allies. The major health groups have been largely absent and the health interests have been poorly represented in standard development. While concentrated in the USA, ASHRAE standards are adopted worldwide.

CONCLUSION

The tobacco industry determined that allowing smoking in ventilation standards for indoor air quality was a high priority and dedicated significant human and financial resources to ensure that its interests were represented. The health groups, until recently, have largely ignored the policy implications for tobacco control of standard development. This situation is changing, but unless health groups maintain high visibility within ASHRAE, the tobacco industry may succeed in creating a standard that ignores the dangers of secondhand smoke.

Evaluating public commentary and scientific evidence submitted in the development of a risk assessment

Risk assessments form the methodological basis for many public policies. A key component of the risk assessment process is the public commentary period. We conducted a case study of the California environmental tobacco smoke risk assessment to describe the contribution of the commentary to the risk assessment process. We used content analysis to examine the sources, quantity, and quality of public commentary, as well as the agency's response to the commentary. We examined the type and quality of publications cited in the commentary. Most of the comments were from critics of the risk assessment (36/44, 80%), especially tobacco industry affiliates (30/36, 83%). Critics were more likely to evoke the science evaluation criteria of study quality, reliability, and validity than were supporters. More than half the critics argued that appropriate procedures were not followed (13/23, 57%). Of the 29 commentaries on the respiratory, carcinogenic, and cardiovascular chapters, four resulted in changes to the risk assessment, such as the addition of new references or reanalysis of data. Journal articles were the most frequently cited type of reference, cited by critics (1,022/1,526 of references, 67%) and supporters (39/60, 65%). However, journal articles submitted by critics had lower impact factors than those cited by supporters (2.6 vs. 3.6, p=0.03). Participation in the public input process was not balanced among all interested parties, although this may reflect different opportunities for stakeholders to participate in stages of the process. Critics and supporters of the risk assessment used different criteria to evaluate the scientific evidence, suggesting that they were socially constructing the evidence to support their positions.