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Tobacco control policy: strategies, success, & setbacks
  1. S F Gambescia

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    de Beyer J, Brigden L W. Copublicaton of the World Bank and Research for International Tobacco Control (RITC), 2003, pp 189, $25.00. ISBN 0-8213-5402-7. paperback.

    Tobacco control policy

    Judging from the title of this work, Tobacco Control Policy, I thought about how the editors would design a different and maybe new policy topology to examine current strategies in tobacco control. That is not their intent. Ostensibly this book is an account of how six countries advocated for and passed tobacco control policies. The editors believed that if we could hear the stories of how tobacco control was defined, approached and implemented at the national level, from around the world, we would not only learn new strategies but also become more inspired in our work.

    The editors created six tobacco control policy case studies—Bangladesh, Brazil, Canada, Poland, South Africa, and Thailand—by interviewing 11 contributors who where central figures in their countries’ tobacco control movements. The editors sensed that while we spent hours in conferences learning about the rationale, approaches, and theoretical analysis of tobacco control policy, the rooms lit up when central figures told their behind the scenes stories of how they battled the socio-cultural, political and economic odds to effect change to improve the health of their citizens.

    Each case study begins with a brief account of the nature and extent of the tobacco use problem in the country and the history of attempts at controlling tobacco use. Tobacco control efforts are then placed in a cultural, political, and economic context so the reader can appreciate barriers that are not always self-evident in our data driven accounts of tobacco control. The authors then address the current climate and most recent and future attempts at tobacco control in their countries. Each account ends with lessons learned so we can transfer some principles and practices to our future attempts at tobacco control.

    The editors believe that when we hear the stories, success or failure, from central figures who were involved in effecting change, the information is more indelible and, consequently, more useful for application in tobacco control.

    The editors and contributors were disciplined in their accounts of these behind the scenes stories. The narratives were cogent, impressive, and easy to follow. They resisted simply conveying colour commentary that, while at times may be more interesting, risk political, organisational, or individual bias. However, the work does give just desserts to those central figures or social and health reform groups who made real contributions to effect change, often against all odds. Sometimes these tobacco control contributors, while working hard for the cause, avoid the limelight—during or soon after advocating for change—for politically strategic reasons.

    Similarly the case studies were not shy about pointing out what groups were conspicuously absent from proactively advancing tobacco control policy. For example, in Canada the authors felt that “many of the individuals and organizations with mandates to reduce disease are still playing only a minor role in the efforts to enact healthy public policies on tobacco control” (p 72).

    Generally, the lessons learned in each of the cases are about what a seasoned tobacco control advocate would expect, such as the importance of an evidenced based rationale for change, building strong coalitions, identifying a political entrepreneur, media advocacy, strategic public relations, economic connections, and willingness to commit to and persevere for the cause.

    I found a major contribution of the project illuminating the nuances of tobacco control as we move around the globe. Seasoned tobacco control advocates can become jaded by the “common thread” lessons mentioned above, but will pause when the authors drill down to expose barriers peculiar to their county.

    We learn in this work, for example, that in Bangladesh, the rationale for tobacco control was built on issues of poverty, nutrition, and human rights and not necessarily adverse health effects. The tobacco lobby in Brazil built lobbying strength grossly imbalanced with the crop’s contribution to the national economy. While Poland is considered a developed country, the health effects of cigarette smoking were censored and a high percentage of health professionals, especially men, still smoked as recent as the late 1980s. We know that we must be willing to fight for causes in advancing public health policy measures, but in some countries it would be ineffective to not cooperate with the government, even when they are slow to adopt high impact measures. While we are familiar with the adage, all politics is local,2 Thailand was actually successful in creating a health burden rationale with data from other countries, because they did not have the epidemiological infrastructure to show the smoking and health burden connection.

    Reading of these case studies could give tobacco control advocates the stimulus, structure, and useful style to write tobacco control stories at various geopolitical levels. Having participated in such an exercise at the state level,1 I found this to be not only challenging to get an accurate rendition of our successes and failures in the state, but a useful reflection to identify that there is much more that needs to be done to reduce the burden of tobacco use.

    The editors note in the beginning of the book that there are common threads and lessons to be learned among these geopolitically disparate countries. They offer these as a laundry list in the beginning of the book and at the end of each chapter. The work could have been stronger if the editors made a final summary of connecting how the common threads and lessons could be applied to future tobacco control efforts.

    Some of the case studies could be difficult for the new students of tobacco control to appreciate. The work does succeed in one of its overall goals to energise and motivate—both novice and stalwart—to continue to exude passion and perseverance in the fight to control tobacco worldwide.