Exam-related Tobacco Policy in non-European country

Independently investigate drivers of a policy problem, author a stakeholder assessment report, and design a policy evaluation strategy.

what are tobacco industry stakeholders

* shareholders & investors
* Employees, contractors
* Supplier companies and farmers
* Customers, distributor shops
* Adult consumers, illegal minor consumers
* Governments and regulators
* Scientific and public health communities
* Key opinion leaders, experts and academics
* International organisations - UN, WHO
* Standards orgs - International Organization for Standardization (for product regulation)
* Law enforcement agencies, ministry of health of the country
* NGOs
* Media and journalists
* Local communities and the general public

how can these stakeholders be identified (stakeholder involvement)

* official consultations with everyone at the table
* E.g. Citizen’s Assembly
* policy advocacy groups to lobby for patients w CVD & cancer from tobacco
* research and development - evidence based policies
* social media tools → surveys & polls for opinions

stakeholders power positions (positive & negative)

* ==**tobacco supplier companies**==
* exploit farmers (even if farmers want to stop, they cant, their life depends on the money)
* they mislead society about economic importance, saying that the country depends on tobacco farming which is a huge part of the economy (GDP), so if theres regulations against that the country will suffer → thats why they back away
* ==**consumers**==
* once ur addicted, its diffifcult to go back
* depends how much support country offers and has focus on this issue (MHD programs, rehab, etc.)
* %%Law enforcement agencies, ministry of health of the country%%
* power to voice the negatives about illegal acts (minors accessing it, self growing), health is being destroyed (CVD and cancer)
* but then depends how much focus country puts on this
* %%Standards orgs%%
* have power to regulate how much goes into a product, packaging, etc.
* based on scientific evidence
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what is the ex-ante effect in evidence informed policy

* being able to ask critical questions about the research evidence available to support advocated policies

what is the ex-post effect in evidence informed policy

* Ensure that evaluations of their initiatives are appropriate and that the outcomes being measured are realistic and agreed in advance

what is the ex post evaluation part in the policy cycle? (6)

* To examine whether policies have the intended effect and how they can be improved, see unintended consequences
* incl %%**6 concepts**%% (policy problem evaluation, process evaluation, time-trend analysis, quasi experim. study, longtitudinal obs. study, economic evaluation)
* May be pursued by independent researchers or researchers affiliated with the government
* E.g. think tanks, research groups, national government have in-house analysts (PhD level researchers working on research)

what does policy problem evaluation in ex post look like?

* WPR method: what’s the problem represented to be → Policy makes problems in a certain way by integrating particular facts and values
* can see underlying assumptions of policy and reveals hidden/silenced things that are focused on
* What is the problem represented to be? What assumptions underlie? How has this representation of the problem come about? What is left unproblematic in the problem representation?

what does process evaluation in ex post look like?

* Examining how well a policy is delivered
* esp. with qualitative methods to give in-depth information
* multiple types of stakeholders need to be interviewed for a full picture (e.g. those who designed the policy, those who are affected by the policy, and those who enforce the policy)

what does time-trend analysis in ex post look like? pro & con

* Examining trends in outcome measures before and after implementation, with cross-sectional monitoring data that is representative for the general population
* Advantage: showing the impact of policies on the population level; produces powerful evidence for media and policymakers


* Disadvantage: changes in the outcome measures may not be caused by the policy; there may b changes before implementation

what does quasi experim. study in ex post look like? pro & con, stat

* Examining changes in outcome measures in a country where policy is implemented %%(intervention group)%% and comparing this to changes in outcome measures in a country/region where the policy is not implemented %%(control group)%%
* to see if policy caused changes, use proximal outcome measures (awareness, support, salience) instead of distal outcome measures (health behaviors)
* Advantage: showing the real-world population-level impact and still having a control group
* Disadvantages: comparability of the control country/region
* stat: regression analysis to see relationship between two variables, if it makes sense, then policy is good (bro im done fr)

what does a longitudinal observational study in ex-post look like? pro & con, stats test

* Examining changes in outcome measures among the same group of people (longitudinal) before and after the implementation of a policy
* No control group, exposure can be a variable in analysis
* advantage: cheap, can be done with quantitative and qualitative methods, possible to look at within-person changes
* Disadvantage: changes in the outcome measures may not be caused by the policy
* stat: ANOVA to compare group means

what does cost evaluation in ex post look like?

* comparative analysis of interventions in terms of cost and consequence
* Helps to make the best decision for optimal resource allocation
* **Cost-benefit analysis:** cost of the intervention is compared with the benefit from the intervention (both expressed in money)
* **Cost-effectiveness analysis:** cost of the intervention is measured against the effectiveness of the intervention (consequences are expressed in natural units like life years gained or improvement in health status)
* **Cost-utility analysis:** cost of the intervention is measured against the ‘utility’ related to health (expressed in quality adjusted life years, QALY’s, or disability adjusted life years, DALY’s)

what is the ex ante evaluation part in the policy cycle? (2)

* how policies can best be designed and implemented
* how much and which effects can be expected
* **experimental study** and **simulation study**

what is the policy cycle?

* agenda setting (identify issues)
* formulate (impact assessment)
* adopt (support & advice to regulatory bodies)
* implement
* evaluate (efficiency & effectiveness with ex ante & post)
* support/maintenance (crisis response, feedback)

what does experimental study in ex ante look like? pro & con, stat

* examine mechanism of policy that is not implemented yet
* randomise study participants in experimental & control group
* stat: differences in primary & secondary outcome measures
* maybe t test to compare means in control and intervention group
* pro: good for causal conclusions
* cons: weak external validity

what does simulation study in ex ante look like? pro

* Mathematical model with ‘synthetic’ data of a population to make **predictions**
* e.g. covid predictions in the future
* Each **‘individual’ in the dataset can switch between stages** (e.g. healthy, diseased, dead) and this is modelled for a period of time


* then, program the **probabillity of switching between states** is modelled with historical data on population size and distribution, mortality rates, fertility rates, disease rates, and prevalence of behaviors (e.g. substance use)
* The model contains assumptions of the impact of policies, which then, the assumptions on the population are examined
* advantage:
* Useful for examining the impact of different policy options
* used to disentangle the impact of simultaneously implemented policies

3 types of agenda

public: issues that get attention from citizen

media: issues that get attention in media

political (gov and decision agenda): issues that r discussed by policymakers for decision making

what is the multiple streams framework

* helps with shaping crisis in a policy window to encourage policy creation (in agenda setting)
* consists of three independent streams: problems, policy solutions, and politics
* problem: tobacco smoking health issue
* policy solutions: r there any policies, r they good enough
* politics: who’s in power, priority focus

what is transposition

* putting EU directives into national MS law

what are the 4 policy instruments to implement policy + EU instruments

* govs confront public problems via the %%use of information%% (for example, public information campaigns, research inquiries, and advertising).
* govs confront public problems via the %%use of legal powers%% (for example, command and control regulation, and self-regulation).
* govs confront public problems via the %%use of money%% (for example, loans, subsidies, taxes)
* govs confront public problems via the %%use of their formal organizations%% (for example, delivering goods via (semi-)governmental organizations, such as defence, education, water supply)
* EU uses → treaties, case law from court of justice, international agreements, soft law

3 main Europeanisation theories

* how well the policy fits
* international relations traditions (how nations work together)
* cooperative decision making culture

What is implementation and dissemination?

**Dissemination**: spreading evidence-based interventions to the target audience via determined channels using planned strategies

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**Implementation**: integrating evidence-based interventions within a setting

what are the 4 steps of implementation

1. formulate goal w clear objectives
2. analyse context (stakeholders, determinants) and if there’s support for this
3. select implementation strategies with causal evidence that it may work
4. evaluate implementation (how many know the interv. what are barriers and facilitators)

what are characteristics of the innovation side that could speed up adoption of policy

* which intervention is seen as better
* compatibility of the intervention with “existing values, past experiences, and needs of potential adopters”
* whether the potential adopters perceive it as satisfactory, acceptable
* fit and relevance of the intervention
* practicability of an intervention
* cost impact of an implementation

what is a implementation gap

difference between what policy maker intended and what actually happens

some enabler/barrier to adoption of policies

* opinion leaders: anyone powerful who can change someone opinion on tobacco (esp. in social media)
* change agent: whole agencies that influence new changes within a group/org
* contextual factors: political, social, organisational, culture, legislation
* organisational readiness & organisation & norma/perceptions: if itll be easy for them to handle the new tobacco policy

bottom up and top down approaches

bottom up: using local/regional stakeholders (patient advocacy groups, national & regional institutions, NGOs) to influence & help government in changing tobacco policies

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top down: high level decides national tobacco policy for local level/general pop.

behaviour change wheel

* understand behaviour and design interventions guided by it
* COMB: capability, opportunity, motivation of the individual
* red part (inside) meso level, intervention functions: changing environment, educating (e.g. public tobapcco campaigns)
* grey part (outside) macro level, policy categories: guidelines, legislation, fiscal measures, etc.

why does implementation gap happen

Reasons why: resistance, not enough money, different understandings of the policy among stakeholders

what is confounding

* study looking at owning a lighter and cancer cases → will show strong correlation
* smoking would be a confounder, the hidden factor that actually causes the cases (instead, they focused on lighters)

Formulate what constitutes good performance for tobacco policies

* decrease in smoking
* decrease in cancer & CVD cases
* sales of tobacco decreases
* ppl are less willing to buy tobacco
* QoL, improved life
* attempting to quiet, successfully quitting

dependent & independent

dependent: health outcome, improved QoL, etc.

independent: the cause, such as smoking, or the lighter, or any other variables that is analysed as the cause

methdology of an evaluation study (qualitative, quantitative, sources of data, stats)

quali: interviews (about smoking behaviour, participatory approach study

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quanti: depends on policy, either quasi or long. observational study

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sources of data: national register for cases, sales records, interview data, PH research data

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stats: depends on study either regression or ANOVA, cost-benefit analyses, etc.

what is decentralisation

* "away from the centre" → handing over of the central government’s power to a lower level of the government, transfer of powers and activities to the sub-national level and actors

what are the decentralisation types

* **Deconcentration/administrative** → shift limited managerial authority to different levels of central gov, breaking up and divesting big firms to reduce the degree of concentration
* Example: Lisbon Treaty, health insurance companies
* **Delegation →** massive leadership except for financial decision-making authority, shifting to particular functions from one person (e.g. leader or manager) to another
* in administrative law → process that divides administrative action or decision-making to a lower level of agency
* **Devolution →** political decentralization, transfer of power by a central government to local or regional administrations (tasks of policymaking, managerial, financial autonomy)
* more democratic
* this needs 6 requirements: constitutional reforms, development of pluralist political parties, strengthening legislature, creating local units, more active public interest groups, capacity building of decentralized authority

which type of decentralisation is more decentralised?

deconcentration is less decen. & devolution is most decentralised

difference of policy vs law

* Policies are only documents and not law, but these policies can lead to new laws
* laws → set standards, procedures that must be followed in society
* made for justice in society
* law is for society justice, a policy is framed for achieving certain goals

what are key areas in a health system reform

* regulation → tobacco regulation policy
* service delivery → decrease selling of tobacco
* financing → financing public campaigns to stop, packaging production
* resource generation & allocation → evidence from cancer research to finance the campaigns, allocate resources like nicotine patches, rehab options for addicted, education

wicked problem, how to solve

tobacco is a wicked problem with being complex, unpredictable, open-ended, resistant to solution

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they have a lot of powerful stakeholders, unpredictable increasing “trends” such as vaping, hard to stop

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solve: adding stakeholders to discussion (broader overview, systems thinking),

primary vs secondary stakeholder

* **Primary** stakeholder → the ppl primarly affected by the project or intervention

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* **Secondary** stakeholder → the ppl not directly affected by the policy but can be involved directly/indirectly in decision making

types of political systems (7)

* **pluralism:** *power is dispersed throughout society, such that no one (group/person) holds absolute power*
* **elitism:** *belief that a society/system should be led by elite*
* **liberal democracy:** democratic government with stable political institutions with the dissemination of power (usa)
* **egalitarian authoritarian:** closed ruling elite, state-managed popular participation, social security system and access to health care ensured by state (cuba, china)
* **authoritarian-inegalitarian:** associated with military government and autocratic ruling, lack voice of ppl, health policy reflected interests of elite and provision was OPP
* **populist:** single/dominant political party, highly nationalist & leadership tends to be personalised, elites keep influence on government 
* **traditional inegalitarian:** ruled by traditional monarchs, Few opportunities for civil participation (saudi)

what are some sources of power

* social/political position of an actor
* organisational culture
* economic position of an actor

what is a risk when trying to satisfy all stakeholder interests + solutions

* very difficult to satisfy all of your stakeholders interests → dissatisfaction can come across as barriers for implementation, which can hinder the outcome of the policy itself
* solutions
* evidence-based
* lots of stakeholders
* democratic, understanding, open-minded, inclusive leadership

problem analysis steps (workshop 1 with causal mindmaps)

* decide aim for solving issue
* choose stakeholders
* group them
* find important categories
* draw causal connections
* make sure everythings collected
* verify & review map