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What facilitates policy audacity in tobacco control? An analysis of approaches and supportive factors for innovation in seven countries
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  1. Marita Hefler1,2,
  2. Eduardo Bianco3,4,
  3. Shane Bradbrook5,
  4. Daniëlle Arnold6,
  5. E Ulysses Dorotheo7
  1. 1 Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
  2. 2 NHMRC Centre for Research Excellence on Achieving the Tobacco Endgame, School of Public Health, The University of Queensland, Herston, Queensland, Australia
  3. 3 Regional Coordinator for the Americas, Framework Convention Alliance, Montevideo, Uruguay
  4. 4 Tobacco Expert Group, World Heart Federation, Geneva, Switzerland
  5. 5 Ngāi Tāmanuhiri, Rongowhakaata, Ngāti Kahungunu, Aotearoa, New Zealand
  6. 6 Health Funds for a Smokefree Netherlands, Utrecht, The Netherlands
  7. 7 Southeast Asia Tobacco Control Alliance, Manila, Philippines
  1. Correspondence to Dr Marita Hefler, Menzies School of Health Research, Charles Darwin University, Casuarina, Australia; marita.hefler{at}menzies.edu.au

Abstract

Background Tobacco control policy audacity can make radical ideas seem possible, and set in motion a ‘domino’ effect, where precedents in one jurisdiction are followed by others. This review examines tobacco control policy audacity from seven countries to identify and compare factors that facilitated it.

Methods A targeted search strategy and purposive sampling approach was used to identify information from a range of sources and analyse key supportive factors for policy audacity. Each case was summarised, then key themes identified and compared across jurisdictions to identify similarities and differences.

Results Included cases were Mauritius’ ban on tobacco industry corporate social responsibility, Uruguay’s tobacco single brand presentation regulations, New Zealand’s Smokefree Aotearoa 2025 Action Plan proposals and 2010 parliamentary Māori Affairs Select Committee Inquiry into the Tobacco Industry, Australia’s plain packaging legislation, Balanga City’s (Philippines) tobacco-free generation ordinance, Beverly Hills City Council’s (USA) ordinance to ban tobacco sales and the Netherlands’ policy plan to phase out online and supermarket tobacco sales. Each case was one strategy within a well-established comprehensive tobacco control and public health approach. Intersectoral and multijurisdiction collaboration, community engagement and public support, a strong theoretical evidence base and lessons learnt from previous tobacco control policies were important supportive factors, as was public support to ensure low political risk for policy makers.

Conclusions Tobacco control policy audacity is usually an extension of existing measures and typically appears as ‘the next logical step’ and therefore within the risk appetite of policy makers in settings where it occurs.

  • tobacco industry
  • public opinion
  • public policy
  • advertising and promotion
  • end game

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Introduction

Policy audacity—defined here as approaches and policies which are the ‘firsts’ globally, or create new paradigms in specific regions or countries, and which require policy makers to move beyond what has already been implemented elsewhere—is important for progressing tobacco control. Once implemented, the ‘impossible’ becomes normal—from smoke-free workplaces, restaurants and pubs, to tobacco health warning labels, banning tobacco advertising and mandating tobacco product plain packaging.1 These precedents are important to make radical ideas seem possible2 and set a ‘domino’ effect in motion,3 whereby multiple jurisdictions follow.

In some cases, policy innovation in one jurisdiction can stand as the only example for many years before others follow, as in the case of graphic health warning labels. First implemented in Iceland in 1985, they were abandoned in 1996 to harmonise with weaker EU legislation. It was 2001 before Canada then became the second ‘first’ country to adopt them. Canada’s lead was rapidly followed by others, but the delay between Iceland and Canada was due to extensive, systematic interference by the tobacco industry which recognised the enhanced effectiveness of adding graphical elements to text-only warning labels.4

In 2004, Bhutan was the first country to ban cigarette sales completely.5 While no other country has yet followed, the concept of phasing out tobacco sales has been discussed within tobacco control for several years, pushing back against the spectre of prohibition,6 laying out the logical case for ending sales of the most lethal consumer product in history7 8 and how this imagined different future might be achieved.9–12 Two US city councils have now enacted ordinances prohibiting tobacco sales from 1 January 2021, with others planning to follow.13 In 2021, 148 organisations signed a letter calling on governments to start planning to end combustible tobacco sales.14 After Australia implemented tobacco plain packaging in 2012, England was the next country to do so in 2017. By October 2020, 17 countries had legislated the measure.15

Although many examples of policy innovation pre-dated its entry into force in 2005, the WHO Framework Convention on Tobacco Control (FCTC) has accelerated the development and implementation of tobacco control legislation.16 However, challenges persist to full FCTC implementation in many countries, and progress globally is uneven.17 18 Furthermore, Article 2.1—which encourages parties to go beyond minimum FCTC obligations and therefore has the potential to facilitate policy audacity—is largely neglected, particularly in relation to supply side measures.19

Understanding what facilitates policy audacity can help shift the tobacco control policy paradigm forward and accelerate progress towards societies free from tobacco’s harms. The aim of this review is therefore to examine examples of policy audacity in diverse contexts to identify and compare factors that facilitated it.

Methods

Initial examples of policy audacity were identified by the author, based on knowledge of ground-breaking initiatives gained from her experience as Tobacco Control news editor from 2012 to 2021. Colleagues (coauthor EUD and others listed in acknowledgements) who have been involved in global tobacco control for several years, based in a range of countries, and who have collaborative networks across multiple countries were consulted to suggest additional examples. The initial list of policy approaches is shown in table 1 (in chronological order).

Table 1

Initial examples of tobacco control policy audacity identified by authors and tobacco control colleagues

To capture the diversity of policies, jurisdictions and information sources, a targeted search strategy and purposive sampling approach was used to identify and analyse key information about selected strategies. Some documents were already known to authors, who were familiar with the cases. Searches for additional information were conducted using Google, Google Scholar and PubMed and the Tobacco Control website using terms specific to the jurisdiction and policy innovation. A systematic review was not suited to this research, given that the story of policy audacity in some cases would need to be gleaned from disparate and non-peer-reviewed sources. Search terms are provided as online supplemental file 1.

The aim was to examine cases representing diverse contexts (geographically, culturally and income level), and which were either supported by government or reached a point in the legislative process where they did, or are likely to be, passed into law. Following the initial search, the Hungary policy was excluded due to insufficient information available in English, and criticism that the motivation for the policy was for reasons other than advancing public health.20 The Tasmanian policy was also excluded, given it was introduced by a member of parliament who was independent rather than a government member, and lapsed without being debated by the Tasmanian parliament.21

Material was included if it provided information that told the story about who introduced the policy or strategy, how it was developed, and if it quoted, interviewed or was the work of decision-makers or key people involved in the policy or approach. Both peer-reviewed literature and grey or nonpeer-reviewed sources were included.

All cases were drawn from publicly available material in English, except the Uruguay example which was drafted by coauthor EB, who was involved in the policy development and implementation. Each case was summarised by the first author, and key contextual and supportive themes identified. These summaries were then refined and clarified by co-authors in each country (Aotearoa New Zealand, Balanga City and Netherlands) or others involved in the development of the policy (Mauritius, Beverly Hills) to ensure accuracy and no key details were missed. These were then compared across jurisdictions to identify commonalities and differences.

Results

The documentation available ranged from comprehensive, authoritative historical timelines and analyses of the policy context in which audacity occurred, published in peer-reviewed literature (Mauritius,22 23 Aotearoa/New Zealand,24 25 Australia,26 27 to academic blogs (Aotearoa/New Zealand,28 detailed online presentations,29 media reports30 31 and in-depth interviews32 with key policy makers, as well as ordinance study sessions33 (Beverly Hills), webinars34 35 and blog articles36 by civil society organisations (Netherlands), PowerPoint presentations by key policy makers,37 media reports,38 blogs39 40 and short case studies41 (Balanga City). Cases are presented below in the order in which they were announced.

Mauritius: ban on tobacco industry corporate social responsibility (CSR)

Mauritius led the world when it implemented a comprehensive ban on tobacco industry CSR in 2008.23 42 It was one of several measures including graphic warning labels, expansion of smoke-free areas, a complete ban on advertising, promotion and sponsorship and numerous restrictions on marketing introduced in the 2008 Public Health (Restrictions on Tobacco Products) Regulations, which were an amendment to the already strong Public Health Act of 1999. Together, the 2008 amendments closely conformed to FCTC requirements and made tobacco control policy in Mauritius one of the most stringent in Africa.23

The groundwork for future action was laid with the 1999 Act, overseen by the Minister of Health & Quality of Life (MOH&QL) who was a strong supporter of tobacco control and was supported by strong technical capacity of senior bureaucrats. From 2001, a new antitobacco NGO, ViSa (now VISA), was formed. It received limited funding support from government23 and provided support to policy-makers, as well as fulfilling a role of monitoring and exposing tobacco industry activities, and using data to lobby government for revisions and tightening of tobacco control regulations (p. 455).22 It also included staff who had previously been senior bureaucrats at the MOH&QL, and cooperated with other domestic NGOs and a number of international NGOs.22 VISA was keen to cultivate a harmonious working relationship with MOH&QL, where power for tobacco control policy making is highly centralised,22 and which was instrumental in advancing the tobacco control policy agenda and increasing its influence with decision-makers.

After the 1999 Act prohibited tobacco advertising, the tobacco industry engaged in a comprehensive range of CSR programmes as a form of proxy advertising. However, VISA actively monitored CSR initiatives and responded by highlighting and undermining the goodwill such initiatives were designed to generate. For example, each year when tobacco industry-funded undergraduate scholarships to the University of Mauritius were announced, VISA would write to the university, student recipients, the media, government and others to bring attention to the fact that these scholarships were being provided by a killer industry.22 Making clear the extent to which tobacco industry CSR was undermining the advertising ban made banning CSR an obvious next step when the 2008 regulations were developed.

The 2008 amendment was also made possible by the appointment in 2005 of another Health Minister, Dr Rajeshwar Jeetah, who was highly committed to tobacco control and influential within the government. He saw political opportunity for Mauritius to be a tobacco control leader as one of the early FCTC signatories (p. 449).22 Other supportive factors were muted influence and opposition from non-health ministries such as agriculture or finance because of the limited domestic tobacco industry (pp. 449–450) and using the existing Public Health Act to create amendments based on the FCTC to avoid tobacco industry interference to slow the legislative process (pp. 451–452).22

Uruguay: tobacco packaging single presentation regulation

In August 2008, the Uruguay Ministry of Health passed a regulation restricting tobacco companies to selling only one unique presentation of each cigarette brand effective from February 2009. Uruguay remains the only country worldwide to implement this measure.

The policy was introduced during the presidency of Dr Tabaré Vázquez, a medical doctor and oncologist, with a keen interest in public health.43 Dr Vázquez became president on 1 March 2005, 6 months after Uruguay ratified the FCTC in September 2004, and a week after it came into force in 27 February 2005. His presidency marked the start of a new tobacco control era, although the groundwork had been laid for several years. Since 2000, there was a strong national civil society tobacco control movement, spearheaded by the National Medical Association. In 2004, the movement promoted and succeeded in creating an Honorary Advisory Commission on Tobacco Control within the Ministry of Health (MOH). Borne out of the close professional networks in this small country, the Commission provided a rapid advisory channel to both the Minister of Health and Dr Vázquez. Members of the Advisory Commission included national cancer, cardiovascular and addiction experts. A National Tobacco Control Program was also established, which worked closely with the Advisory Commission.44

From May 2005, Uruguay began to implement WHO FCTC measures by decree. Among the first was a decree related to WHO FCTC Article 11, which banned misleading descriptors such as light, mild, ultralight and low tar. In March 2008, parliament approved a new Tobacco Smoking Control Act which included a specific provision to combat the fraud of misleading descriptors. The tobacco industry reacted by using brand variants including colours such as golden, silver and green, and other variants appeared to circumvent and undermine the regulation.

The MOH and its Advisory Commission discussed two measures to counteract the tobacco industry strategy: plain packaging and increasing health warning label sizes to 80%. At the time, the MOH considered that plain packaging would unleash great resistance from the tobacco industry.44 It therefore opted for the strategy of single presentation per tobacco brand family. The idea for this approach came from a 2005 paper published by Physicians for a Smoke-Free Canada,45 which members of the Commission were aware of through longstanding international collaboration.

The Uruguay example demonstrates the value of a body with deep technical expertise to provide direct advice to government, informed by collaborative international networks and the ability to draw on a range of policy approaches to fit within acceptable risk parameters.

Aotearoa New Zealand: proposals for a Smokefree Aotearoa 2025 and the Māori Affairs Select Committee (MASC) Inquiry into the Tobacco Industry

In April 2021, the Aotearoa New Zealand government published Proposals for a Smokefree Aotearoa 2025 Action Plan. Strategies include drastically reducing tobacco retail availability, denicotinisation of tobacco products and a smokefree generation strategy. Central to the plan is Māori leadership and sovereignty.46

The scene was first set for this world-leading plan in September 2009, when Aotearoa New Zealand Māori party member of parliament Hone Harawira announced the Māori Affairs parliamentary select committee would hold an inquiry into the impact of tobacco use on Māori, with the aim of increasing public pressure for banning the sale of tobacco.47

The resulting report, published in November 2010,48 provided comprehensive recommendations for a Smoke-free New Zealand, including holding the tobacco industry accountable and reducing the availability of tobacco. It also recommended that Māori approaches and decision-making be adopted. This approach was bold because using an Inquiry rather than the usual Health Select Committee process was a political pathway which had never been done before. However, it was aligned with public support and set the scene for measures that ‘logically have a high chance of success, but that have not been implemented or evaluated before’. The government was therefore encouraged to ‘be brave enough to implement such ground-breaking interventions, but also to evaluate them to ensure they are actually effective and cost-effective’.20 The MASC report led to the then-government committing to a 2025 smoke-free goal.28

In the lead up to the announcement of the MASC, a detailed overview of recent actions by Māori politicians and advocates was published.25 These included Māori leaders shifting the goal posts from tobacco control to elimination, as part of a move to increased control and sovereignty for their own well-being, and against harm, as well as taking control of the language—introducing the terms ‘auahi kore’ (smoke-free) and ‘tupeka kore’ (concept of tobacco-free). Both terms were adopted more broadly by both Māori and government organisations.

Denormalisation was another important focus, using media and advocacy to change social norms, putting the focus on and acting against the tobacco industry. The language used in these efforts was uncompromising, using terms such as ‘Māori murder’, ‘endangered species’, ‘tobacco resistance movement’ and ‘genocide’, a deliberate use of words associated with criminal law, environmental campaigns and liberation rhetoric. Support for denormalisation campaigns came from both mainstream and Māori media.25

The MASC led to a ‘reset’ of tobacco control, which was struggling. The Associate Minister for Health at the time, Dame Tariana Turia, was a champion of the goal as co-leader of the Māori Party; she received the report and strongly recommended it to parliament. However at the 2014 election, she retired and the Māori party became less influential in the coalition government, led by the National Party which had longstanding tobacco industry alliances.49 Although several years of inaction and reduced tobacco control funding followed,50–52 the MASC created a foundation for the Smokefree Aotearoa Action Plan proposals following the 2020 election of a Labour government.

The Aotearoa example shows the importance of leadership from those most affected by tobacco use to shift the paradigm of tobacco control, the need for collaboration across different groups (Māori and non-Māori, academics and civil society organisations as well as government), the value of focusing on the culpability of the industry and how the framework for policy can carry forward even as government commitment waxes and wanes.

Australia: tobacco plain packaging

On 29 April 2010, the Australian government was the first in the world to announce it would adopt tobacco plain packaging. The bill was passed into law on 1 December 2011 and fully implemented from 1 December 2012. The timeline, key players, Australian health policy context and history of plain packaging research and evidence has been comprehensively documented by Australian tobacco control researchers26 27 who were involved in various capacities in development and advocacy for the policy.

As Australian Health Minister from December 2007 to December 2011, and then Attorney General until her resignation in February 2013, Nicola Roxon was the key political figure responsible for steering the bill through parliament and laying the groundwork for it to withstand the inevitable, and protracted, tobacco industry legal challenges. Asked ‘what made the government take such an important step’, Roxon highlighted the critical role of the solid evidence base suggesting it would be effective, the reputation and coherence of the Australian tobacco control community and the supporting expertise of the public (civil) service, legal profession and public health sphere (pp. 118-124).26 Roxon’s then chief of staff also noted that the year before the party was elected to government was crucial for laying the policy groundwork. During this time, advice was regularly sought from key public health researchers, showing the importance of cultivating relationships across party lines, which many health groups maintain in Australia (p. 131).26

Other factors that helped finally bring plain packs—an idea which had been around internationally since the mid-1980s (p. 1)26 to fruition include the long corporate memory of key advocates, who were working in tobacco control when the tobacco industry successfully scared the Canadian government from adopting it in the mid-1990s (pp. 5–6).26 In the intervening years, internal tobacco industry documents released in the USA formed the basis for a detailed report which showed the legal arguments the industry used to be false (pp. 6–7).26 Cynthia Callard, a Canadian tobacco control expert who analysed the documents, was interviewed on a major Australian current affairs programme to highlight the hollowness of the tobacco industry’s strategy (p. 21), demonstrating the value of both international collaboration between academics and civil society, and ongoing scrutiny and analysis of tobacco industry activities.

Leveraging high public support to minimise public distrust of the tobacco industry to garner bipartisan commitment (pp. 135–136), and high support to minimise the potential political risk were also important (p. 24), as was continuing public advocacy in support of the move during an 8-month information vacuum about whether the measure was likely to succeed (p. 23).26

Balanga City, Philippines: tobacco-free generation (TFG) Ordinance

Balanga City passed a TFG Ordinance in 2016, the first jurisdiction in the world to do so, preventing the sale and use of all tobacco and e-cigarettes products to anyone born on or after January 2000.40

Two figures were pivotal in developing and passing the policy: Councillor Jernie Jett V Nisay (health committee chair), and former mayor Jose Enrique Garcia, who were both drivers of a comprehensive approach to health promotion and the Philippines Department of Health healthy lifestyle campaign Pilipinas Go4Health.38 Mayor Garcia is also a graduate of the 2014 Johns Hopkins Bloomberg School of Public Health Institute for Global Tobacco Control Leadership Program and won an award for his tobacco control leadership at the 2016 World Conference on Tobacco or Health.39

With overwhelming public support, the TFG Ordinance was introduced in September 2016. It followed a March 2016 Ordinance which had already essentially created a completely smoke-free city by expanding the coverage of a 2008 ban on the sale, distribution, use, advertising and promotion of tobacco products within three kilometres of Balanga City’s 80-hectare University Town area by an additional three-kilometre radius and including e-cigarettes.40 Taking into account the long history of comprehensive action to promote Balanga as a tobacco-free city, the TFG ordinance was the next logical step in the larger tobacco control landscape.

Tobacco control is itself one component of a much larger participatory health promotion approach for Balanga to promote healthy eating, physical exercise and being alcohol/drug-free, as part of its identity as a ‘world class university town’.37 The tobacco industry subsequently won legal challenges against both ordinances—hinting at the industry’s view of the potential effectiveness of these strategies.40

Beverly Hills, USA: ordinance to prohibit most tobacco sales

Then mayor of Beverly Hills, John Mirisch, was pivotal to the city’s decision to adopt an ordinance to ban tobacco sales in 2019. In a February 2021 webinar to discuss moving Spain towards the tobacco endgame,29 Mirisch outlined the history of Beverly Hills’ action on tobacco control, particularly to introduce and expand smoke-free areas in the city since 1987. Among the innovations he had been personally involved in as part of his council role since 2014 were treating e-cigarettes the same as tobacco, prohibiting smoking in farmers’ markets, and in 2017 making all multiunit housing completely smoke-free.

The genesis of the policy to end all tobacco sales was a 2018 council discussion about banning tobacco product flavourings. Mirisch recalled asking ‘Why not just ban tobacco altogether?’ The city’s Health and Safety Commission then initiated a process to research policy options and prepare recommendations to council, for which public input was invited. In February 2019, the council held a study session about the issue. Among other tobacco control experts and groups, Ruth Malone (UCSF and TC editor-in-chief) and Chris Bostic (ASH USA) spoke about the historical context of the tobacco industry and legal justification;33 both were subsequently quoted by Mirisch about the justification for the policy.29

In both presentations29 and interviews,30 32 Mirisch repeatedly highlighted the aspiration for Beverly Hills to be a healthy city, the importance of doing what is right and appropriate for the community, his pride at Beverly Hills being the first jurisdiction to end tobacco sales and hope that other cities would follow its example. In a longer and more wide-ranging interview, he also talked about his personal values and political orientation as a ‘communitarian’ not a ‘corporatist’, an orientation clearly not naturally aligned with an industry whose profits are at the expense of its customers’ health and lives.32 Fellow councillors also highlighted the city’s focus on health, and the appropriateness of not taking part in selling tobacco.31

Netherlands: phasing out tobacco sales online and from supermarkets

In 2020, the Dutch government presented a policy plan which included two concrete measures: a ban on online tobacco sales to come into force in 2023, and a ban on supermarket tobacco sales to enter into force in 2024.34–36 The step represented a stunning reversal for a country that less than 10 years ago was labelled a Nirvana for the tobacco industry.52

The innovation was supported by an alliance formed between the Dutch Heart Foundation, Dutch Cancer Society and Lung Foundation in 2013,34 35 which was quickly joined by approximately 40 additional organisations. The alliance’s approach was to find the ‘fastest road towards a smokefree Netherlands’, focusing on feasible and effective FCTC strategies.35 A joint strategy was developed to generate broad social and political support. In 2015, the alliance launched the ‘smokefree generation’ movement.34 35 It focuses on protecting youth, with the intention that children born from 2017 and after would be free from exposure to smoking. This is an important strategy to generate public and political support from all sides—it is a framing that nobody is willing to go against and ensures messaging is both positive and supportive.35 Using public support is a key strategy to influence government; from 2009, the alliance did annual surveys of public attitudes to reducing tobacco outlets. In 2020, it showed an increase in support to 71%–73%, up from 61% to 62% in 2016.34

From 2019, a national prevention agreement was adopted in the Netherlands, which focuses on tobacco, alcohol and obesity, and creates societal and government collaboration. It includes a range of tobacco control measures including reducing the number of tobacco points of sale, for which FCTC Article 2.1 is an important guiding point. The proposed plan to end online and supermarket tobacco sales is the first step in a strategy to ultimately restrict tobacco sales to specialist shops.34

While it is yet to be tested by implementation, the road to this policy demonstrates the importance of cohesion between civil society organisations to achieve targeted goals, and making the policy low-risk politically through both the choice of framing and leveraging public support, and the importance of building support across political lines.

Discussion

A common feature of all the cases was that they were grounded in strong theoretical evidence for potential effectiveness, built on a foundation of existing tobacco control and substantial history of comprehensive action, drawing on political capital and community support which made the policy a relatively low political risk.

At the local government level (Balanga City and Beverly Hills), a high degree of community engagement and linking tobacco control policy to the identity of the community were prime supporting factors, as were local policy makers who are tobacco control ‘champions’ and willing to invest in this as part of their political identity. These more audacious supply side measures may offer significantly greater scope for health gains for cities and communities, as opposed to individually-focused measures, such as promoting smoking cessation and other approaches to reduce demand for tobacco products.

At the national level, cohesion between civil society and governments (Mauritius, Uruguay, Netherlands), including relationships across political party lines (Australia, Netherlands), strong bureaucratic and technical expertise (all), global and local tobacco control knowledge and memory (Uruguay, Australia) and international collaboration (Mauritius, Uruguay) and incorporating lessons learnt from previous unsuccessful tobacco control policy innovation (Australia) are all supporting factors. Framing issues in such a way that they foster and harness public antipathy towards the tobacco industry, coupled with leveraging public support for smoking reduction (Aotearoa, Australia, Netherlands), assists in making policy audacity a low-risk option for politicians. As with local government regulations, strong policy-making champions within government were crucial in all the national examples.

A strength of this study is that it integrates information from diverse sources, including the voices of policy makers themselves, as well as those involved in approaches and policy making. It includes a range of contexts and policy-making approaches, at both the local and national government level. In addition, while all the policy approaches included in this study were either legislated or supported by government, it includes a policy that was subsequently repealed by a successful tobacco industry legal challenge (Balanga City) as well as two that have not yet been fully implemented (Aotearoa New Zealand, Netherlands). A limitation of the study is that it excludes non-English language material, and no policies that were introduced to legislatures but not passed. Examples such as the Tasmanian smoke-free generation bill may provide useful lessons for policy makers, researchers and advocates in other jurisdictions.

Conclusion

Tobacco control policy audacity which is ground-breaking typically appears as ‘the next logical step’ in settings where it is adopted. Building on previous initiatives within the jurisdiction, as well as anticipating the likely feasibility and potential for approaches to withstand tobacco industry challenges assists with balancing boundary-pushing innovations against the risk appetite of policy makers. FCTC Article 2.1 encourages Parties to go beyond minimum measures specified in the Treaty, but has historically been neglected. As Parties increasingly move towards full FCTC implementation, policy audacity is needed to progress towards achieving societies free from the harms of tobacco.

What this paper adds

  • Paradigm-shifting audacity in tobacco control policy has the potential to improve public health in the contexts where it is implemented and also serves as important precedents for other jurisdictions.

  • As Parties increasingly move towards full Framework Convention on Tobacco Control (FCTC) implementation, policy audacity, as encouraged by FCTC Article 2.1, is needed to progress towards achieving societies free from the harms of tobacco.

  • Despite the importance of policy innovation for achieving tobacco-free goals, there is limited evidence for what facilitates policy audacity across different jurisdictions.

  • This study examines diverse examples of audacity in tobacco control policy in seven countries to identify factors that facilitated it. Strong civil society support, research evidence, alignment of policies with local identity and tobacco control champions are all important factors for facilitating policy audacity.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication

Acknowledgments

The authors wish to thank Anaru Waa, Coral Gartner, Joanna Cohen and Richard Edwards for providing useful information, references and ideas for examples of policy audacity. We also thank Deowan Mohee and Chris Bostic who provided comments and clarifications about the Mauritius and Beverly Hills policies, however any errors or omissions remain the responsibilty of the first author. Thanks also to the anonymous reviewers who provided helpful feedback to improve the paper.

References

Footnotes

  • Twitter @m_hef, @biancoeduardo1

  • Contributors MH performed initial searches and prepared the first draft of the manuscript. All authors contributed to preparing the case studies and final version of the paper. MH has overall responsibility for the work and acts as guarantor.

  • Funding MH is the recipient of a Gender Equity Fellowship from the Menzies School of Health Research, Darwin, Australia. She also receives salary support from the Australian National Health & Medical Research Council grant (GNT1198301), Centre for Research Excellence on Achieving the Tobacco Endgame through the University of Queensland.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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