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There is a time honoured metaphor in public health about a river, a cliff, and people who fall from the cliff into the river. The metaphor describes the expensive ambulances and the heroic rescue and resuscitation services that can be arranged to retrieve and revive those who are drowning. It acknowledges that those drowning are very grateful for these services and conversely, that a lot of politically damaging fuss can be made if innocent or important people are left to drown.
As for the cliff, the metaphor points out that fences erected at the top would prevent a lot of people from falling in. But it points out that fences can be ugly, that they disrupt views, and that as dull, static and unchanging objects they don’t attract the same attention as bright, shiny ambulances or dramatic rescue routines. Above all, a fence does its job when nothing happens, whereas a rescue service is successful when it is very busy. The erection of a fence provides one photo opportunity for a politician whereas dramatic rescues can provide dozens.
At some juncture, some of those who staff the ambulances begin to realise that things have gotten out of hand. They grow tired of providing photo opportunities for politicians and scratch their heads wondering why people continue to fall into the river. Suddenly, they point to the cliffs and gasp at those that are unfenced. Some leave their posts to become fence builders.
Despite the obvious message of the metaphor, there are many unfenced cliffs in tobacco control and many others that are poorly designed and unattended. Yet fences, like advertising bans, significant increases in excise tax, and bans on smoking in workplaces, are the most coveted goals in tobacco control policy because they hold potential to influence every smoker and potential smoker. How ironic then, that our knowledge of the processes that best facilitate the demand for, implementation of, and strengthening of such policies is so incomplete and ad hoc, when by contrast, it is possible to be nearly buried in an avalanche of formative research about tobacco control’s downstream activities.
Popular and unpopular prevention
Like the fence/river or upstream/ downstream metaphor, a useful distinction has been made between “popular ” and “unpopular” prevention. This difference is hardly better exemplified than in the case of many nations’ records in tobacco control. Popular prevention “spawns programmes that are piecemeal, cosmetic, ineffective, fun, and futile”,1 sometimes reducing smoking prevalence among their small, select target groups while being rarely funded sufficiently to impact in whole communities or national populations. Popular preventive strategies almost always fail the public health test of being capable of influencing tobacco use throughout populations. Instead, they typically operate within clinical, therapeutic, or small scale educational settings where career structures have long been established to reward individually oriented prevention. Most revealingly, they are characterised by upsetting no one – especially the tobacco industry. There can be no more telling index of effectiveness than the tobacco industry’s own enthusiasms for particular strategies. The industry has often gone out of its way to actually join the chorus of those calling for more “popular ’ preventive work: an Australian Rothmans executive wrote to the press of his company “fully supporting sensible and effective public education.”2 In the United States, two large scale “education” campaigns – the Tobacco Institute’s “helping youth say no” campaign and RJ Reynolds’ “right decisions, right now’’ – have been described as cynical damage control exercises and almost by definition, object lessons to health educators in what not to do in tobacco control.3,4
By contrast, the often unpopular prevention of the sort discussed in this supplement is policy oriented. It takes aim at the social, economic, and political factors that facilitate a climate where, in World Health Organisation (WHO) terminology, the choice to smoke remains an easy choice. Unpopular prevention often involves adversarial relations between health workers and indifferent, reluctant, or downright oppositional governments and bureaucracies, and of course the tobacco industry and its beneficiaries. The history of smoking control is full of such groups resisting the implementation of the now well known platforms of a comprehensive tobacco control policy:
Excise tax policy based on raising the real price of tobacco
A total ban on all forms of tobacco advertising and promotion
A comprehensive and enforced approach to banning smoking in all enclosed public spaces
Dedicated on going funding for mass reaching information campaigns, including mandated antismoking school curricula
A comprehensive effort to eliminate access of the young to tobacco products
The mainstreaming of advice on cessation and minimal intervention programmes into routine health care settings
Strong and prominent pack warnings, including generic packaging a low tar policy, preferably involving maximum tar ceilings
The ending of all financial assistance to the tobacco growing industry.
Unpopular prevention is sometimes called passive prevention because, as with examples like tobacco tax, the removal of vending machines, and reform of pack labelling, little or nothing is required of the consumer. Governments must have the will to take the steps that have the power to influence every smoker and future generations of smokers. The day to day tactics that eventually result in government policy shifts in the huge vested interest arenas like tobacco advertising can often seem out of court to the orthodox health worker. The tactics and strategies of advocacy and lobbying are not easily described in terms of “programmes”. What is due in unpopular prevention seldom lends itself to precise statement as an independent variable capable of direct replication by others. There are few definable, inviolate steps amenable to the requirements of the “methods-results-discussion” format demanded by journals and which seem to define the boundaries of the acceptable in popular prevention. There are few publications on the “how to” of public health advocacy,5 and courses on strategies are taught in only two Master of Public Health courses around the world known to us (University of California, Berkeley and the University of Sydney). Yet ironically, the record of advocacy in advancing upstream preventive measures that impact on whole populations gives this activity an unparalleled importance.
Political decisions to introduce tobacco control laws, regulations, policies and programmes often, although not always, reflect research findings. Publicity arising from research can inspire politically influential media and community debate about tobacco control policies as well as feed directly into particular decision making forums such as state treasury concerns about potential loss of revenue from a decline in smoking.
It is a salutary experience to scan through a database like Medline and look at the range of published research on tobacco control. It is clear that policy or public health oriented interventions, which have the greatest potential for population wide effect, have received short shrift. It is almost as if there is an inverse research law operating in tobacco control: the more trivial the intervention from a public health perspective, the greater the concentration of research; the greater the potential for population wide effect, the scarcer the research effort. We hope this supplement will become a major factor in redressing this curious and troubling imbalance. The contents of this supplement are a testament to the breadth and the complexity of the research tasks that we face in improving the number and design of the upstream fences in tobacco control. Few will need reminding that this complexity is compounded by there being few places set at funding tables for those who want to pursue policy research, a problem that is by no means confined to the tobacco control field. Part of the historical disinterest in policy research derives from scientists’ and funders’ sense that policy research is tainted by its determined, necessary link with politics. Traditionally, science is supposed to be “pure,” isolated from political considerations, and unlikely to offend. Unfortunately, this view is no longer tenable. Particularly in tobacco control, the very research that will most benefit the public cannot be divorced from (and indeed, is inextricably linked with) political considerations.
This is a first attempt at putting together research priorities in the field of tobacco control policy research. It will thus serve as a benchmark for future reports and it will be interesting to return to its pages in five years to see how many questions that have been asked will then be well understood or have become redundant. It will be clear to most readers that there are some important gaps here: what impact have tobacco industry political donations had on tobacco control policies and how can this best be considered?6 How should research be conducted into how best to place health warnings on packs and into the potential of generic packaging to reduce the appeal of smoking?7 What are the most productive forms of coalition building and lobbying activity for tobacco control? And what about tobacco control policy research in most developing countries where tobacco control has little public or political support? These and other areas deserve our attention too.
The American Cancer Society (ACS) and the Advocacy Institute (Washington, DC) had the vision to conceive, plan, and run the meetings which gave rise to the reports in this supplement. Without this leadership and the financial support from the ACS, the publication of such material would have inevitably been delayed and denied our field the benefit of the impetus to research that these collected reports will hopefully bring.
In particular, Dr Ruth Corcoran from the ACS and Mr Mike Pertschuk of the Advocacy Institute must be especially thanked. They attended all meetings and assisted with most reports. Their energy and leadership deserve much thanks.