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‘Balancing acts’: The politics and processes of smokefree area policymaking in a small state
Health Policy 101 (2011) 79–86
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‘Balancing acts’: The politics and processes of smokefree area policymaking in a small state Helen Wilson, George Thomson ∗ University of Otago, Wellington, Box 7343, Wellington South, New Zealand
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Keywords: Smokefree area policy Nanny state Evidence-based policy Smoking Children
a b s t r a c t Objective: To examine the influences on contemporary smokefree area policy development in New Zealand. Method: Semi-structured interviews were conducted with 62 New Zealand politicians and senior officials. They were asked about their views of possible interventions to reduce smoking around children, and how to achieve progress on smokefree homes, cars and public places. Transcribed data were analysed for themes, some of which were determined by the questions asked, and some emerged from the dynamic nature of the interviews. Results: Policymaking for smokefree areas was seen by participants as a complex, highly politicised activity, concerned with balancing a number of factors including evidence, personal experience, concern for smokers, and the desire for public support for policy. The majority of participants were cautious about making substantive policy moves on smokefree places because of their perception of the issue as highly controversial, their wish to avoid public resistance and their desire for community engagement. Preference was shown for a policy approach based on persuasion rather than legislation, as a means to make progress on smokefree cars and outdoor spaces. Conclusions: The results indicate the need for good communication of the acceptability and benefits of legislative smokefree changes to both the political and public arena. © 2010 Elsevier Ireland Ltd. All rights reserved.
1. Introduction The making of public policy is a complex process, influenced by a number of considerations such as cost, public opinion, political ideology, experience and evidence [1]. The complexity of policymaking is heightened for issues which are, or are perceived to be, controversial or emotive. Small wonder then, that Chapman has identified tobacco control, which is frequently considered to interfere with personal rights and freedoms, as a ‘fraught, highly politicised activity’ [2] (p. 29). This complexity, and the extent of other influences, can diminish the role of evidence. Policymaking has been
∗ Corresponding author. Tel.: +64 4 385 5541x6054; fax: +64 4 389 5319. E-mail address: [email protected] (G. Thomson). 0168-8510/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2010.08.017
described as the ‘science of ‘muddling through’ [3], using ‘jumbled and diffuse processes’ [4], and influenced by ‘messy realities’ [5]. Among other things, these realities include the public acceptability of policies and electoral fall-out [6], personal experience and interests [4,7], and a ‘loose information system’ comprising ‘[i]deas, rumours, bits of information, studies, and lobbyists’ pleadings’ [6] (p. 77). Because of the limited research into the complexities of policymaking for smokefree areas (henceforth smokefree policies) [8–10], especially as seen by policymakers [11,12], we used an inductive qualitative study to explore some of the influences on contemporary smokefree policy development in New Zealand. New Zealand has a unicameral Westminster style parliament with elections at least every three years, elected since 1996 by a Mixed Member Proportional system. This has created a series of coalition governments which require
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inter-party agreement for legislation, a factor which has slowed the creation of laws [13]. As in many jurisdictions, there are further complications from the ability of business and community interests to influence policy [14,15]. There is evidence that the tobacco industry has been successful in reaching Members of Parliament with its ideas [16], and the company with the major market share, British American Tobacco, has made efforts to project itself as a responsible business [17]. Only one company (Imperial Tobacco) has a manufacturing plant in New Zealand, which is small and has a low public profile. The industry concept of ‘adult choice’ has strong resonance with much of New Zealand political thought. New Zealand has had effective smokefree legislation for most indoor public places and for offices since 1990, and for all indoor workplaces (including bars) since 2003 [18]. Research has indicated strong public and smoker support for extending smokefree regulations to cars containing children [19], and to playgrounds [20]. Since 2003, 2004 and 2006 respectively, government media campaigns for smokefree workplaces [21,22], homes [23], and smokefree cars [24], have been run intermittently. 2. Methods This qualitative study used purposeful sampling to recruit for in-depth interviews, in order to better describe smokefree policy development [25]. The interviewees were selected from groups of: (i) politicians who currently had, or had had some role in health promotion or tobacco control policy in the previous five years, or had commented publicly on such policy in that period; (ii) senior government officials who were in a position to affect or comment on health promotion or tobacco control policy; (iii) officials in related non-governmental organisations (NGOs) who were involved in such policy; and (iv) current members (elected or appointed) of District Health Boards (DHBs). We approached both opponents and supporters of tobacco control. To help achieve a balance in Members of Parliament (MPs) from the two main political parties, we also approached 20 National Party and 14 Labour Party MPs. A semi-structured interview schedule was prepared to address the research aims, derived from the literature and previous research knowledge. The schedule included questions on participants’ views and knowledge of the risks of children smoking and the effects of secondhand smoke, possible general and particular interventions to reduce smoking around children, and how to achieve progress on smoking in homes, cars and outdoor public places. Interviews with those policymakers who were identified as of Maori (indigenous) and of Pacific Island ethnicity were conducted by Maori and Pacific interviewers. Interviews were on the basis of anonymity, and were designed to elicit personal rather than organisational views. Permission was obtained through the University of Otago Human Ethics process for the conduct of the interviews. The interviews, during April 2009 to February 2009, took between 25 and 45 min, and were audio-recorded. Transcribed data were analysed for themes, some of which were determined by the questions asked, and some emerged from the dynamic nature of the interviews (unex-
pected themes were found in the interviewees’ responses, and from the interviewer posing follow-up questions). Both authors read the transcripts, with one doing the initial manual theme coding. Themes identified in a preliminary analysis were adapted and changed as further themes or sub-themes were identified on closer analysis (after transcript re-reading), and after discussions between the authors [26,27]. Themes were re-checked against the data by the authors as part of these discussions.
3. Results From 53 national or regional politicians, and 54 officials, we recruited 62 participants (acceptance levels of 58% overall—41% of politicians and 81% of officials). The participants included 17 MPs, 5 DHB members, 37 government officials and seven NGO officials (four had been government officials). Of the 17 MPs recruited; four were from the National Party, four from ‘center’ parties (New Zealand First, United Future and the Maori Party), seven from the Labour Party, and two from the Green Party. Of ¯ all the participants, 17 (27%) were Maori (indigenous New Zealanders) and 18 (29%) were of Pacific Island ethnicity. ¯ Both Maori and Pacific communities are over-represented among smokers in New Zealand [28]. All participants were either ex- or non-smokers, although this was not a criterion of participation.
3.1. Making policy Findings from the data support the view that smokefree policymaking is seen by policy insiders as a complex and highly political activity. Participants drew attention to the challenges surrounding the policy and legislative processes. Comments included: ‘The view of the policy process from outside of the policy process . . . will be very different from what it is if you’re working inside the policy environment. . .policy decisions are made often in very interesting ways.’ (Official 1) ‘Interesting ways’ may be a euphemism for aspects of policymaking not grounded in scientific evidence, because, as another official explained: ‘. . .all of us . . . are bringing to the table a whole range of prejudices, value systems, half-baked ideas about how the world works, partially understood bits of research.’ (Official 2) There was a strong overall theme that policymaking is a balancing act requiring the weighing up of competing interests, motivations, and demands. Five particular aspects of this theme were identified when exploring the making of smokefree policies. These related to the tension between evidence and other competing considerations; the influence of personal experiences and feelings; concerns about the ‘nanny state’ and public acceptability of policy; the need to engage the community for the workability of policy; and concern for smokers.
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3.2. Evidence versus political viability The notion that evidence is just one of a number of factors influencing policy activity was supported by the study data. Although most participants mentioned evidence as a key factor in deciding policy, this was frequently qualified by comments on the constraints to evidence-based policy. One such constraint was the need for politicians to make ‘trade-offs’ between competing interests. Evidence alone was not considered enough to change policy: ‘There’s plenty of evidence and research. . . But the politics around [tobacco policies]. . .. . . those are public policy trade-offs that only ministers and government can make.’ (Official 3) Even when the role of evidence was given prominence (for example, one interviewee used the word ‘evidence’ or ‘evidence-base’ 11 times), limitations to its impact in the face of other policy considerations were often mentioned, even in the next breath. For example: ‘I think it is very much the case of, on the one hand, being able to have a strong argument, not an anecdotal one, but an evidence-based one. And on the other hand, the balance [with] just how far forward you go.’ (Politician 1) ‘The priorities are [set] by politicians. Sometimes evidence is taken into account sometimes not, and sometimes it is purely political.’ (Official 4) Getting the balance right was seen as a difficult – and at times unresolved – activity: ‘The research . . . is there. . . there is every scientific reason why you would do it but . . .political issues are the number one barrier.’ (Politician 2) ‘[Politicians] are very often balancing a range of viewpoints and interests and considerations. . .’ (Official 1) ‘What’s useful, what’s effective, what’s practicable, what’s politically acceptable, are all different things. And I think at the end of the day, it’s what’s going to be politically acceptable that. . .we, in the bureaucracy at least, need to take account of.’ (Official 5) 3.3. Personal experiences and feelings Attitudes towards smoking and therefore smokefree policy positions were at times affected, not by scientific evidence or larger political considerations, but by the personal experiences or feelings of participants. For instance, some participants remarked on the unpleasant experience of having to walk past smokers outside bars and/or bus stops. One framed this in terms of his/her rights as a nonsmoker: ‘I find smoking in the street an increasing problem, particularly as a non-smoker, . . . you actually have to walk through, sometimes, a wall of smoke to get to your destination, and I don’t enjoy it, and I don’t enjoy following somebody else down the street that’s . . . smoking either. . . . I think we do have some rights too.’ (Politician 3)
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One participant made it clear that personal experience had influenced her/his stance on smoking in public spaces, although s/he was not in support of legislating for smokefree cars containing children: ‘I actually favour extending the prohibitions in public enclosed spaces, into some other public environments that are adjacent to those enclosed spaces. So, for example, I find it totally galling to go to a café, where inside, sure, that’s smokefree, but if I want to sit outside in the fresh air, in the sun, actually, it’s colonised by smokers. So . . . that would be a legitimate and worthwhile extension.’ (Politician 4) Another politician talked of weighing best practice against his/her ‘instinct’—with the latter winning: ‘I would then get an official and say, ‘I want you to go and look at best practice, come back with opposing [views] for this’, and I’ll match it up against what [the smokefree advocate says]. And I’ll then make a decision based on my instinct, probably, my gut feeling.’ (Politician 5) The personal experience of quitting evoked in one participant an ambivalent attitude towards the addictive nature of cigarettes: ‘They say it’s hugely addictive. I didn’t find it hugely addictive, but I found the habit hard. I still reached for my cigarettes for a long time afterwards. But nothing more than that, really.’ (Politician 6) 3.4. The ‘nanny state’ and the public acceptability of state power One of the dominant themes emerging from the data was that smokefree policies should be acceptable to the public. This was considered essential by both officials and politicians, in order to avoid complaints of state interference in people’s lives. A common refrain was that civil libertarians, the parliamentary opposition, or other groups, would cry ‘nanny state’ in response to any policy that infringed the freedom of adults to smoke. For example: ‘[Y]ou’d have all the libertarians saying we’re controlling people’s freedom, and they have the right to make their own choices, so you’d have that group, the ‘nanny state’ [opposers].’ (Official 6) ‘I think the government has a huge role. It has to be very careful about that role, because you get this ‘nanny state’ [idea] which people tend to kick back against.’ (Politician 6) The extent of their concerns about the ‘nanny state’ was illustrated by the number of participants who used imagery of warfare to illustrate their perceptions of the politics around smokefree policy. Interviewees variously saw tobacco control as a ‘constant battle’ (Politician 7), a ‘battle of [the] public’s opinion’ (Official 7), a ‘war’ (Official 5), and a ‘battleground’ (Politician 8). The metaphors suggested the participants’ expectations and fears of public resistance: ‘Kiwis. . .aren’t all that keen about being told what they can do. So there’s a bit of a resistance, often, to being told
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what to do, and this. . .would be seen as a restriction of adult freedoms.’ (Official 8) ‘[The government] has to be very careful about that [public health] role . . . those things can be done in a sensitive manner. . . . they can’t be too heavy, otherwise people will rebel.’ (Politician 6) In spite of this notion of a resistant or even rebellious public, a number of these same participants commented on the (at times unexpected) positive public reaction to the 2003 legislation which outlawed smoking in bars and restaurants in New Zealand. ‘I am amazed at the people who say that they’re delighted that there’s no smoking in bars anymore.’ (Politician 6) ‘Bars are going to be smokefree in a year’s time, and everyone screamed. . .moan, moan, moan. Bang, in it came, and no moaning. One or two, but on the whole they just accept it. Then they realise, “Actually, this is bloody good.”’ (Official 9) Nor was this enthusiasm seen to be confined to nonsmokers: ‘[W]hen [bars became smokefree] lots and lots of people really loved it and. . .most smokers want to give up and so anything that reduces their consumption. . .they like it as well.’ (Politician 9) And one respondent suggested that ‘a leap of faith’ might be necessary in some policy moves: ‘[Smokefree bars have] been a phenomenal change . . . And yet [now] everybody loves it. Absolutely loves it. And so. . . you just do it. In circumstances like that.’ (Politician 10) However, it is perhaps a reflection of the perceived power of the ‘nanny state’ idea, or of over concern for preventing discord from a particular sector of society, that only one participant made the significant connection that the large majority of New Zealanders are not smokers. Accordingly, this person expected sufficient support for smokefree measures: ‘So I don’t know what the political risk is here, because the majority of people are not smokers. And the majority of people, even smokers, favour tightening up on these things so it’s only sort of civil libertarians who think it’s your right to do anything you want.’ (Official 10)
3.5. Engaging the community In contrast to the notion of compulsion by an intrusive state, which participants were largely uncomfortable with, was the suggestion that public acceptance of smokefree policy can be achieved through other, less ‘authoritarian’, means. This issue was highlighted by the interviewees who talked of the need to ‘take your public with you’ (Official 6), ‘to take people with you’ (Politician 3), ‘to change people’s mindsets’ (Official 11) or to capture ‘hearts and minds’ (Officials 1, 4). Several drew on the empowerment
discourses of community development to expand on the idea of persuasion, rather than legislation, as a strategy to get communities onside. For example: ‘[I]t’s OK that a law doesn’t necessarily get implemented instantaneously. . .a law often sows very strong seeds in a community and in people’s minds, which with time – and sometimes not that long – empowers people or enables them to implement it themselves and in not a terribly top-down way.’ (Official 8) There was a strong emphasis on the importance of community support by the majority of Pacific respondents. This was demonstrated by the frequent comments that, if they are to be effective, policies need to have community buyin, and/or be driven at a grass roots level (Officials 3, 4, 12, 13, 14, 15; Politicians 17, 18) For example: ‘[Y]ou go out to the community and you ask them what they think and . . . that is why some of the things are working, because they have developed the priorities for their community and they drive it, rather than [government] policies. . . [un]like the patronising . . . ‘You must do this’ approach.’ (Official 12) ¯ A number of Maori participants also talked about the need for community support in terms of ‘ownership: ‘The government has got to . . .put a little bit more faith in our communities that they actually know what they are doing. It gives it that good community ownership. . .Our communities. . .are able to maintain those strategies and programme themselves because they believe in it and it’s theirs.’ (Official 16) ‘I think you have got to have. . . community support and buy-in, because they’re ultimately providing the deepest reach into the homes and the households.’ (Politician 13)
3.6. Concern for smokers Interviewees mentioned the difficulties for smokers, such as addiction, a lack of resources, stress and family dysfunction or other similar concerns. One participant, at least, made it clear that this view impacted on his/her policy stance: ‘I’m ambivalent on [smokefree outdoors] ‘cos I’m sympathetic to people who. . .find it really difficult to give up. I’m sympathetic to people who. . .the stresses and strains of whose life means that they haven’t got a show in hell of giving up, and. . . the people at the bottom end of the socio-economic spectrum are absolutely caught in this.’ (Official 6) Some participants positioned smokers as the hapless victims of smokefree policies: ‘I think society’s shifting with smokers outside. . .I mean it looks bad, it’s freezing cold, you feel sorry for them, people must feel. . .like a pariah, or a leper. . .They’re out there and you see them and you think, ‘Oh, you poor thing.’ (Politician 5)
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‘I believe it’s time we brought the smokers back in, and said it wasn’t about you, it was about exposure to second hand smoke, we’re not trying to get at you. In fact, we know you need and deserve the very best support to help stop smoking, and we’re going to provide it for you. . . So do something for the smokers.’ (Official 1) One participant suggested policy solutions are influenced by the way smoking is framed in terms of responsibility and blame: ‘[Y]ou always have to frame [smoking as] an addiction. So you have diminished responsibility because of that addiction. . . it’s about reframing it . . . and the way we are doing it is taking the responsibility away from the individual by actually. . . blaming someone else, and that’s the tobacco industry.’ (Official 9) The perception of the tobacco industry as an underlying problem was relatively uncommon in the data. However, some participants identified the industry as an obstacle to smokefree policy change: ‘There’s . . . a proportion of smokers who feel that there’s enough restrictions already, and don’t want government to intrude anymore. The industry itself is obviously going to be supportive of any people who want to take a stand [on this argument].’ (Official 12) ‘They’re very powerful. Tobacco, alcohol, gambling, all those lobbys are extremely powerful, and extremely well connected. Very difficult . . . They’ve got more money.’ (Official 16) Part of the lack of policy emphasis on the industry was seen as due to their low public visibility: ‘The visible industry in NZ is actually the local dairy [corner shop].’ (Official 4) 4. Discussion Policy activity around smokefree areas was seen by interviewees as a highly politicised activity, involving the difficult and constant balancing of a number of competing interests, motivations and demands. Although we have identified five main themes, this is not to imply that they represent consistent or clearly fixed views or positions of participants. On the contrary, there were discontinuities and contradictions within and across texts, reflecting the fraught and fractured nature of the policy process. 4.1. The role of evidence for smokefree policy It has been argued that ‘because social science is merged with other knowledge, officials. . .have great difficulty disentangling the lessons they have learned from research from their whole configuration of knowledge’ [4]. If this is the case, the absence of a clear linear progression from research to policy does not necessarily indicate a lack of rationality in decision-making [4,29]. However, while the need for evidence to inform policy was woven to varying degrees through the data here, the findings suggest that policymaking for tobacco control is
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a process in which research plays only a relatively small part, when weighed up against a number of other, often highly political, imperatives, such as the need for public acceptability and community engagement to avoid political repercussions. This is consistent with research in the United States which found that the most powerful forces affecting the policy agenda were perceptions by policymakers of a ‘national mood’ and electoral fall-out [6]. It is also consistent with the rejection by many New Zealand politicians during 1997–2005 of evidence about secondhand smoke hazards [16]. There are a number of ways in which these perceptions of policymakers may be flawed. As Kingdon says, the ‘national mood does not necessarily reside in the mass public, but instead is perceived in the attitudes of various active sectors of the public’ [6] (p. 162). For instance, the ‘nanny state’ concerns of the New Zealand public about new smokefree policies may have been overstated by the interviewees. Recent research has found strong support in New Zealand by both non-smokers and smokers for extending some smokefree initiatives [19,20,30,31]. However, the perception of public opposition has particular implications for proponents of change to smokefree areas. The political onus usually lies with these advocates, if they are to avoid claims of state interference, to demonstrate that there is public support for what might be considered unacceptable changes. There are exceptions. The comments by some participants that the smokefree bars and restaurants policy was very popular afterwards, despite mixed support at the time of change, are supported by research [18]. This suggests that there is scope for politicians and policymakers to take a more leadership type of approach when making new smokefree policy. 4.2. Concern for smokers versus children The concern for smokers illustrates the complications in devising policies to protect children from being exposed to secondhand smoke and to the role modelling impact from seeing adult smoking. If people are seen to be victims of poverty, stress, or nicotine addiction, it may appear heartless to promote substantive policies which may make their lives even harder. The concern can mean that the focus of policymaker concern is with smokers rather than children (even when the latter are more vulnerable and have very constrained choices). The concern does not even seem to factor in the benefit for smokers who quit or cut down, as a result of smokefree areas. However, these feelings may ignore or obscure smoker support for change. For example, recent research found that over 90% of New Zealand smokers from all socio-economic and ethnic groups supported the banning of smoking in cars with small children [19]. There is also evidence that, in contrast to the view of entrenched smoking behaviours among certain groups, different ethnic and socio-economic groups can respond equally well to quit campaigns [32]. The relative inability of policymakers to see the tobacco industry as responsible for the effects of smoking is evident in other studies of tobacco control policy [33], although sometimes immediate political necessity has obscured even the question of responsibility [8,34]. ‘Concern about
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smokers’ and about other groups is a traditional industry strategy to deflect policy attention from its responsibility [35,36]. 4.3. The impetus for community engagement and leadership It has been said of smokefree policymaking that governments must ‘sense the degree to which the public will follow’ [37]. The study findings, with the emphasis on public acceptability and community engagement, highlight participants’ concern to get public support for proposed smokefree policies. This is also reflected in the preference of many of the interviewees for persuasion rather than legislation, as a means to achieving further smokefree areas. The community engagement focus appears consistent with the argument that the traditional public health discourse, in which there are victims and culprits, is less meaningful today. Instead, contemporary health promotion may avoid intervening, coercing or punishing, by working ‘at a distance’ through collaborative ventures, lobbying for policy change, and promoting community action or community development [38]. This notion of community development underpins the growing emphasis in New Zealand policy documents and statements on community participation and partnership in decision-making, particularly in health [39–44]. Although in practice these concepts may be little more than rhetoric, it is perhaps a reflection of their currency in the New Zealand political arena that they resonate so strongly in our interviewee data. However, in the context of tobacco control, this approach may merely mask a convenient shifting of responsibility for action from government to local communities. In other words, community engagement can be seen as a preferable way to effect individual behaviour change around smoking, while avoiding national-level policy decisions which policymakers anticipate will be unpopular. The question of what should be ‘leadership’ in smokefree policy was implicitly or explicitly raised by interviewees (and is debated in the policy literature) [45]. Letting local leaders drive local policy was clearly attractive to national-level policymakers (as long as there were little negative consequences for them), as there were advantages for communities (more local control) and also for the national level (less heat on national policymakers from objectors to policies). ‘Top-down’ has dangers of unpopularity and non-implementation [46]. A rarer response was that national leadership was needed to get smokefree policies into place, as these would then be appreciated for their benefits by a public, some of whom had been sceptical. 5. Policy implications The wider health sector cannot assume that policymakers have an accurate or rational view of public support for smokefree policies. Policymaker perceptions of these factors may need to be adjusted towards the available evidence, in order to provide some balance to personal experiences and political pressures. However, because of
the complex nature of policymaking, evidence of health effects or support will be only a part of the mix used in the decision processes. Evidence of policy effectiveness in some settings is not necessarily relevant to other settings, due to the local politics and practicality of implementation. Assumptions of the primacy of ‘evidence-based’ policy does not take into account the personal aspects of the policy process, and ‘the mismatch of randomized thinking with nonrandom problems’ [47]. For tobacco control policy, there are further inherent challenges to evidence-based policymaking, including ‘the integration of complex and sometimes conflicting information from authoritative sources’, and ‘the importance of individual versus governmental responsibility’ [48]. While community participation in decision-making may be useful for the local implementation of policy and development of services, it is arguably less prudent for some policies. These include smokefree car laws, which probably require a state or national legislative approach to ensure all disadvantaged and vulnerable groups benefit. While persuasion may always play a part in the policy process, at times the onus is on policymakers to follow logic and available evidence to take a leadership role in protecting public health. As Rein says, ‘Any choice of policy is risky—full of uncertainties and unforeseeable consequences: at some point we have to commit ourselves for better or worse’ [49] (p. 19). How can the complexities of policymaking be navigated to achieve change? We know that some sorts of evidence are particularly attractive for policymakers. Putting numbers to deaths or other tangible outcomes so to make issues more concrete, and giving human faces to issues, helps cut through complexity [16]. Creating a resonant narrative from research evidence means that the evidence can be more persuasive [50,51]. When the evidence narrative clearly offers solutions to policy problems, it is more likely to draw policymaker attention [52]. In order to strengthen the resonance of smokefree policy narratives, mass media coverage of smokefree issues (paid and unpaid) may provide an effective, if longer term, foundation for positive change [10,53]. The New Zealand smokefree media campaigns have provided policymakers with a common series of narratives which they can discuss and argue from with each other, and with the public [21–24].
6. Limitations This case study was limited by the incomplete response rate from officials and politicians who were approached for interviews. Another limitation was the time constraints for some of those who were interviewed, which meant there was less opportunity to explore some of their responses in-depth. Nevertheless, given the amount of repetition of common themes, we are confident that the major attitudes held by of these policymakers were captured in this study. The anonymity of the interviews generally enabled far more candid statements compared to those made in public.
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7. Conclusions Policy activity around tobacco control is considered by New Zealand policymakers and politicians as a balancing act, influenced by a number of competing factors. The political acceptability of policy was seen as paramount, largely outweighing the impact of evidence or other considerations. As a result, most participants preferred a policy approach involving persuasion rather than legislation, underpinned by strong community engagement. As elsewhere, advocates have a continual need to communicate the acceptability of smokefree changes which require legislation to be optimally effective. Acknowledgements The Health Research Council of New Zealand funded this project (the Smokefree Kids Project). We thank Sheena Hudson, Tolotea Lanumata, Linda Tasi-Mulitalo and Kiri Parata who conducted most of the interviews. We also thank our interviewees. Dr. Nick Wilson gave very helpful comments. References [1] Bulmer M, Coates E, Dominian L. Evidence-based policy making. In: Bochel H, Duncan S, editors. Making policy in theory and practice. Bristol: Policy Press; 2007. p. 87–102. [2] Chapman S. Public health advocacy and tobacco control: making smoking history. Oxford: Blackwell Publishing; 2008. [3] Lindblom C. The science of “muddling through”. Public Administration Review 1959;19:79–88. [4] Weiss C. Policy research in the context of diffuse decision making. Journal of Higher Education 1982;53:619–39. [5] Burton P. Modernising the policy process: making policy research more significant? Policy Studies 2006;27:173–95. [6] Agenda KJ. Alternatives and public policies. New York: Longman; 2003. [7] Popay EH. How are policy makers using evidence? Models of research utilization and local NHS policy making. Journal of Epidemiology and Community Health 2000;54:461–8. [8] Bryan-Jones K, Chapman S. Political dynamics promoting the incremental regulation of secondhand smoke: a case study of New South Wales, Australia. BMC Public Health 2006;6(192), doi:10. 1186/14712458-6-192. [9] Freeman B, Chapman S, Storey P. Banning smoking in cars carrying children: an analytical history of a public health advocacy campaign. Australian & New Zealand Journal of Public Health 2008;32: 60–5. [10] Chapman S, Wakefield M. Tobacco control advocacy in Australia: reflections on 30 years of progress. Health Education and Behavior 2001;28:274–89. [11] Cohen J, de Guia N, Ashley M, Ferrence R, Northrup D, Studlar D. Predictors of Canadian legislators’ support for tobacco control policies. Social Science & Medicine 2002;55:1069–76. [12] Andersen PA, Buller DB, Voeks JH, Borland R, Helme D, Bettinghaus EP, et al. Predictors of support for environmental tobacco smoke bans in state government. American Journal of Preventive Medicine 2006;30:292–9. [13] Malone R. Rebalancing the constitution: the challenge of government law-making under MMP. Wellington: Institute of Policy Studies; 2008. [14] Howes M, Lyons K, Bryant S. Civil society revisited: possibilities for increasing community collaboration in a competitive world. In: Australasian Political Studies Association Conference. 2004. [15] Roper B. Business political activity in New Zealand from 1990 ¯ to 2005. Kotuitui: New Zealand Journal of Social Sciences Online 2006;1:161–83. [16] Thomson G, Wilson N, Howden-Chapman P. The use and misuse of health research by politicians during the development of a national smokefree law. Australia and New Zealand Health Policy 2007;4:24.
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[17] Thomson G. Trust us we’re socially responsible: the truth behind British American Tobacco NZ’s corporate social responsibility reports. Auckland: ASHNZ; November 2005. http://www.ash.org.nz/ site resources/library/Research commisoned by ASH/Trust us we re socially responsible.pdf. [18] Edwards R, Thomson G, Wilson N, Waa A, Bullen C, O’Dea D, et al. After the smoke has cleared: evaluation of the impact of a new national smoke-free law in New Zealand. Tobacco Control 2008;17:e2. [19] Thomson G, Weerasekera D, Wilson N. New Zealand smokers’ attitudes to smokefree cars containing preschool children: very high support across all sociodemographic groups. New Zealand Medical Journal 2009;122(1300):84–6. [20] Thomson G, Wilson N, Weerasekera D, Edwards R. Most smokers support smokefree council-owned playgrounds: national survey data. New Zealand Medical Journal 2009;122(1291):122–3. [21] Health Sponsorship Council. ‘Let’s Clear the Air’—second-hand smoke in the workplace media campaign. Wellington: Health Sponsorship Council; 2005 [accessed 14.07.10]. [22] Health Sponsorship Council. Smokefree Legislation Media Campaign. Health Sponsorship Council. Wellington; 2005 [accessed 8.07.10]. [23] Health Sponsorship Council. Smokefree homes. Wellington: Health Sponsorship Council; 2008 [accessed 22.03.10]. [24] Health Sponsorship Council. Make your car smokefree/Kia auahi kore o tatou waka [media campaign]. Wellington: Health Sponsorship Council; 2008 [accessed 22.03.10]. [25] Sandelowski M. Whatever happened to qualitative description? Research in Nursing & Health 2000;23:334–40. [26] King A. Template analysis. In: Symon G, Cassell C, editors. Qualitative methods and analysis in organizational research: a practical guide. London: Cassell; 1998. p. 14–36. [27] Green J, Willis K, Hughes E, Small R, Welch N, Gibbs L, et al. Generating best evidence from qualitative research: the role of data analysis. Australian & New Zealand Journal of Public Health 2007;31:545– 50. [28] Ministry of Health. Tobacco Trends 2008: a brief update of tobacco use in New Zealand. Wellington: Ministry of Health; June 2009, http://www.moh.govt.nz/moh.nsf/pagesmh/9081/$File/tobaccotrends-2008.pdf. [29] Black N. Evidence based policy: proceed with care. British Medical Journal 2001;323:275–9. [30] Health Sponsorship Council. Topline results: 2008 health and lifestyles survey. Wellington: Health Sponsorship Council; November 2009. [31] Wilson N, Blakely T, Edwards R, Weerasekera D, Thomson G. Support by New Zealand smokers for new types of smokefree areas: national survey data. New Zealand Medical Journal 2009;122(1303): 80–9. [32] Ministry of Health. Tobacco use survey 2008: quitting results. Wellington: Ministry of Health; 2009, http://www.moh.govt.nz/ moh.nsf/pagesmh/9665/$File/2008-nztus-quitting-results-nov09v2.pdf. [33] Berridge V. Post-war smoking policy in the UK and the redefinition of public health. Twentieth Century British History 2003;14:61–82. [34] Givel M, Glantz S. Tobacco lobby political influence on US state legislatures in the 1990s. Tobacco Control 2001;10:124–34. [35] Givel M. Consent and counter-mobilization: the case of the national smokers alliance. Journal of Health Communication 2007;12:339–57. [36] Dearlove JV, Bialous SA, Glantz SA. Tobacco industry manipulation of the hospitality industry to maintain smoking in public places. Tobacco Control 2002;11:94–104. [37] Carr-Gregg M. Interaction of public policy advocacy and research in the passage of New Zealand’s Smoke-free Environments Act. Addiction 1993 1990;(January Suppl.):35S–41S. [38] Petersen A. Risk, governance and the new public health. In: Petersen A, Bunton R, editors. Foucault, health and medicine. London: Routledge; 1997. p. 188–206. [39] Ministry of Health. New Zealand health strategy. Wellington: Ministry of Health; 2000. [40] Ministry of Health. Implementing the New Zealand Health Strategy: The Minister of Health’s first report on progress on the New Zealand Health Strategy. Wellington: Ministry of Health; 2001, http://www.moh.govt.nz/moh.nsf/ea6005dc347e7bd44c2566a 40079ae6f/8e1c3e0662669cb2cc256b25000711bd?OpenDocument.
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[41] Ministry of Health. Doing better for New Zealanders: better health better participation reduced inequalities. Wellington: Ministry of Health; 2002, http://www.moh.govt.nz/notebook/nbbooks.nsf/ 8b635a98811e8aed85256ca8006d4e51/3cc8fc6f253ac01fcc256c3d 0081cca7/$FILE/DoingBetterForNewZealanders.pdf. [42] Ministry of Health. Reducing inequalities in health. Wellington: Ministry of Health; June 2002. [43] Ministry of Health. Good oral health, for all, for life. Wellington: Ministry of Health; 2006, http://www.moh.govt.nz/moh.nsf/ pagesmh/5117/$File/good-oral-health-strategic-vision-2006.pdf. ¯ [44] Ministry of Health. Te Whakauruora: Maori suicide prevention resource will empower communities. Mental Health Newsletter 2009;28:7. [45] Jacobs L, Shapiro R. Politicians don’t pander: political manipulation and the loss of democratic responsiveness. Chicago: The University of Chicago Press; 2000. [46] Lee J, Goldstein A, Kramer K, Steiner J, Ezzell M, Shah V. Statewide diffusion of 100% tobacco-free college and university policies. Tobacco Control 2010. Published Online First: 14 May 2010 doi:10.1136/tc.2009.032888.
[47] Brownson RC, Royer C, Ewing R, McBride TD. Researchers and policymakers: travellers in parallel universes. American Journal of Preventive Medicine 2006;30:164–72. [48] Rosen L, Rosenberg E, McKee M, Gan-Noy S, Levin D, Mayshar E, et al. A framework for developing an evidence-based, comprehensive tobacco control program. Health Research Policy and Systems 2010;8:17. [49] Rein M. Social science and public policy. Harmondsworth: Penguin Education; 1976. [50] Sandercock L. Out of the closet: the importance of stories and storytelling in planning practice. Planning Theory & Practice 2003;4:11–28. [51] Schank RC, Abelson RP. Knowledge and memory: the real story. In: Wyer R, editor. Knowledge and memory: the real story. Hillsdale, NJ: Lawrence Erlbaum Associates; 1995. [52] Donnison D. The academic contribution to social reform. Social Policy & Administration 2000;34:26–43. [53] Chapman S, Dominello A. A strategy for increasing news media coverage of tobacco and health in Australia. Health Promotion International 2001;16:137–43.
Contents lists available at ScienceDirect
Health Policy journal homepage: www.elsevier.com/locate/healthpol
‘Balancing acts’: The politics and processes of smokefree area policymaking in a small state Helen Wilson, George Thomson ∗ University of Otago, Wellington, Box 7343, Wellington South, New Zealand
a r t i c l e
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Keywords: Smokefree area policy Nanny state Evidence-based policy Smoking Children
a b s t r a c t Objective: To examine the influences on contemporary smokefree area policy development in New Zealand. Method: Semi-structured interviews were conducted with 62 New Zealand politicians and senior officials. They were asked about their views of possible interventions to reduce smoking around children, and how to achieve progress on smokefree homes, cars and public places. Transcribed data were analysed for themes, some of which were determined by the questions asked, and some emerged from the dynamic nature of the interviews. Results: Policymaking for smokefree areas was seen by participants as a complex, highly politicised activity, concerned with balancing a number of factors including evidence, personal experience, concern for smokers, and the desire for public support for policy. The majority of participants were cautious about making substantive policy moves on smokefree places because of their perception of the issue as highly controversial, their wish to avoid public resistance and their desire for community engagement. Preference was shown for a policy approach based on persuasion rather than legislation, as a means to make progress on smokefree cars and outdoor spaces. Conclusions: The results indicate the need for good communication of the acceptability and benefits of legislative smokefree changes to both the political and public arena. © 2010 Elsevier Ireland Ltd. All rights reserved.
1. Introduction The making of public policy is a complex process, influenced by a number of considerations such as cost, public opinion, political ideology, experience and evidence [1]. The complexity of policymaking is heightened for issues which are, or are perceived to be, controversial or emotive. Small wonder then, that Chapman has identified tobacco control, which is frequently considered to interfere with personal rights and freedoms, as a ‘fraught, highly politicised activity’ [2] (p. 29). This complexity, and the extent of other influences, can diminish the role of evidence. Policymaking has been
∗ Corresponding author. Tel.: +64 4 385 5541x6054; fax: +64 4 389 5319. E-mail address: [email protected] (G. Thomson). 0168-8510/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2010.08.017
described as the ‘science of ‘muddling through’ [3], using ‘jumbled and diffuse processes’ [4], and influenced by ‘messy realities’ [5]. Among other things, these realities include the public acceptability of policies and electoral fall-out [6], personal experience and interests [4,7], and a ‘loose information system’ comprising ‘[i]deas, rumours, bits of information, studies, and lobbyists’ pleadings’ [6] (p. 77). Because of the limited research into the complexities of policymaking for smokefree areas (henceforth smokefree policies) [8–10], especially as seen by policymakers [11,12], we used an inductive qualitative study to explore some of the influences on contemporary smokefree policy development in New Zealand. New Zealand has a unicameral Westminster style parliament with elections at least every three years, elected since 1996 by a Mixed Member Proportional system. This has created a series of coalition governments which require
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inter-party agreement for legislation, a factor which has slowed the creation of laws [13]. As in many jurisdictions, there are further complications from the ability of business and community interests to influence policy [14,15]. There is evidence that the tobacco industry has been successful in reaching Members of Parliament with its ideas [16], and the company with the major market share, British American Tobacco, has made efforts to project itself as a responsible business [17]. Only one company (Imperial Tobacco) has a manufacturing plant in New Zealand, which is small and has a low public profile. The industry concept of ‘adult choice’ has strong resonance with much of New Zealand political thought. New Zealand has had effective smokefree legislation for most indoor public places and for offices since 1990, and for all indoor workplaces (including bars) since 2003 [18]. Research has indicated strong public and smoker support for extending smokefree regulations to cars containing children [19], and to playgrounds [20]. Since 2003, 2004 and 2006 respectively, government media campaigns for smokefree workplaces [21,22], homes [23], and smokefree cars [24], have been run intermittently. 2. Methods This qualitative study used purposeful sampling to recruit for in-depth interviews, in order to better describe smokefree policy development [25]. The interviewees were selected from groups of: (i) politicians who currently had, or had had some role in health promotion or tobacco control policy in the previous five years, or had commented publicly on such policy in that period; (ii) senior government officials who were in a position to affect or comment on health promotion or tobacco control policy; (iii) officials in related non-governmental organisations (NGOs) who were involved in such policy; and (iv) current members (elected or appointed) of District Health Boards (DHBs). We approached both opponents and supporters of tobacco control. To help achieve a balance in Members of Parliament (MPs) from the two main political parties, we also approached 20 National Party and 14 Labour Party MPs. A semi-structured interview schedule was prepared to address the research aims, derived from the literature and previous research knowledge. The schedule included questions on participants’ views and knowledge of the risks of children smoking and the effects of secondhand smoke, possible general and particular interventions to reduce smoking around children, and how to achieve progress on smoking in homes, cars and outdoor public places. Interviews with those policymakers who were identified as of Maori (indigenous) and of Pacific Island ethnicity were conducted by Maori and Pacific interviewers. Interviews were on the basis of anonymity, and were designed to elicit personal rather than organisational views. Permission was obtained through the University of Otago Human Ethics process for the conduct of the interviews. The interviews, during April 2009 to February 2009, took between 25 and 45 min, and were audio-recorded. Transcribed data were analysed for themes, some of which were determined by the questions asked, and some emerged from the dynamic nature of the interviews (unex-
pected themes were found in the interviewees’ responses, and from the interviewer posing follow-up questions). Both authors read the transcripts, with one doing the initial manual theme coding. Themes identified in a preliminary analysis were adapted and changed as further themes or sub-themes were identified on closer analysis (after transcript re-reading), and after discussions between the authors [26,27]. Themes were re-checked against the data by the authors as part of these discussions.
3. Results From 53 national or regional politicians, and 54 officials, we recruited 62 participants (acceptance levels of 58% overall—41% of politicians and 81% of officials). The participants included 17 MPs, 5 DHB members, 37 government officials and seven NGO officials (four had been government officials). Of the 17 MPs recruited; four were from the National Party, four from ‘center’ parties (New Zealand First, United Future and the Maori Party), seven from the Labour Party, and two from the Green Party. Of ¯ all the participants, 17 (27%) were Maori (indigenous New Zealanders) and 18 (29%) were of Pacific Island ethnicity. ¯ Both Maori and Pacific communities are over-represented among smokers in New Zealand [28]. All participants were either ex- or non-smokers, although this was not a criterion of participation.
3.1. Making policy Findings from the data support the view that smokefree policymaking is seen by policy insiders as a complex and highly political activity. Participants drew attention to the challenges surrounding the policy and legislative processes. Comments included: ‘The view of the policy process from outside of the policy process . . . will be very different from what it is if you’re working inside the policy environment. . .policy decisions are made often in very interesting ways.’ (Official 1) ‘Interesting ways’ may be a euphemism for aspects of policymaking not grounded in scientific evidence, because, as another official explained: ‘. . .all of us . . . are bringing to the table a whole range of prejudices, value systems, half-baked ideas about how the world works, partially understood bits of research.’ (Official 2) There was a strong overall theme that policymaking is a balancing act requiring the weighing up of competing interests, motivations, and demands. Five particular aspects of this theme were identified when exploring the making of smokefree policies. These related to the tension between evidence and other competing considerations; the influence of personal experiences and feelings; concerns about the ‘nanny state’ and public acceptability of policy; the need to engage the community for the workability of policy; and concern for smokers.
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3.2. Evidence versus political viability The notion that evidence is just one of a number of factors influencing policy activity was supported by the study data. Although most participants mentioned evidence as a key factor in deciding policy, this was frequently qualified by comments on the constraints to evidence-based policy. One such constraint was the need for politicians to make ‘trade-offs’ between competing interests. Evidence alone was not considered enough to change policy: ‘There’s plenty of evidence and research. . . But the politics around [tobacco policies]. . .. . . those are public policy trade-offs that only ministers and government can make.’ (Official 3) Even when the role of evidence was given prominence (for example, one interviewee used the word ‘evidence’ or ‘evidence-base’ 11 times), limitations to its impact in the face of other policy considerations were often mentioned, even in the next breath. For example: ‘I think it is very much the case of, on the one hand, being able to have a strong argument, not an anecdotal one, but an evidence-based one. And on the other hand, the balance [with] just how far forward you go.’ (Politician 1) ‘The priorities are [set] by politicians. Sometimes evidence is taken into account sometimes not, and sometimes it is purely political.’ (Official 4) Getting the balance right was seen as a difficult – and at times unresolved – activity: ‘The research . . . is there. . . there is every scientific reason why you would do it but . . .political issues are the number one barrier.’ (Politician 2) ‘[Politicians] are very often balancing a range of viewpoints and interests and considerations. . .’ (Official 1) ‘What’s useful, what’s effective, what’s practicable, what’s politically acceptable, are all different things. And I think at the end of the day, it’s what’s going to be politically acceptable that. . .we, in the bureaucracy at least, need to take account of.’ (Official 5) 3.3. Personal experiences and feelings Attitudes towards smoking and therefore smokefree policy positions were at times affected, not by scientific evidence or larger political considerations, but by the personal experiences or feelings of participants. For instance, some participants remarked on the unpleasant experience of having to walk past smokers outside bars and/or bus stops. One framed this in terms of his/her rights as a nonsmoker: ‘I find smoking in the street an increasing problem, particularly as a non-smoker, . . . you actually have to walk through, sometimes, a wall of smoke to get to your destination, and I don’t enjoy it, and I don’t enjoy following somebody else down the street that’s . . . smoking either. . . . I think we do have some rights too.’ (Politician 3)
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One participant made it clear that personal experience had influenced her/his stance on smoking in public spaces, although s/he was not in support of legislating for smokefree cars containing children: ‘I actually favour extending the prohibitions in public enclosed spaces, into some other public environments that are adjacent to those enclosed spaces. So, for example, I find it totally galling to go to a café, where inside, sure, that’s smokefree, but if I want to sit outside in the fresh air, in the sun, actually, it’s colonised by smokers. So . . . that would be a legitimate and worthwhile extension.’ (Politician 4) Another politician talked of weighing best practice against his/her ‘instinct’—with the latter winning: ‘I would then get an official and say, ‘I want you to go and look at best practice, come back with opposing [views] for this’, and I’ll match it up against what [the smokefree advocate says]. And I’ll then make a decision based on my instinct, probably, my gut feeling.’ (Politician 5) The personal experience of quitting evoked in one participant an ambivalent attitude towards the addictive nature of cigarettes: ‘They say it’s hugely addictive. I didn’t find it hugely addictive, but I found the habit hard. I still reached for my cigarettes for a long time afterwards. But nothing more than that, really.’ (Politician 6) 3.4. The ‘nanny state’ and the public acceptability of state power One of the dominant themes emerging from the data was that smokefree policies should be acceptable to the public. This was considered essential by both officials and politicians, in order to avoid complaints of state interference in people’s lives. A common refrain was that civil libertarians, the parliamentary opposition, or other groups, would cry ‘nanny state’ in response to any policy that infringed the freedom of adults to smoke. For example: ‘[Y]ou’d have all the libertarians saying we’re controlling people’s freedom, and they have the right to make their own choices, so you’d have that group, the ‘nanny state’ [opposers].’ (Official 6) ‘I think the government has a huge role. It has to be very careful about that role, because you get this ‘nanny state’ [idea] which people tend to kick back against.’ (Politician 6) The extent of their concerns about the ‘nanny state’ was illustrated by the number of participants who used imagery of warfare to illustrate their perceptions of the politics around smokefree policy. Interviewees variously saw tobacco control as a ‘constant battle’ (Politician 7), a ‘battle of [the] public’s opinion’ (Official 7), a ‘war’ (Official 5), and a ‘battleground’ (Politician 8). The metaphors suggested the participants’ expectations and fears of public resistance: ‘Kiwis. . .aren’t all that keen about being told what they can do. So there’s a bit of a resistance, often, to being told
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what to do, and this. . .would be seen as a restriction of adult freedoms.’ (Official 8) ‘[The government] has to be very careful about that [public health] role . . . those things can be done in a sensitive manner. . . . they can’t be too heavy, otherwise people will rebel.’ (Politician 6) In spite of this notion of a resistant or even rebellious public, a number of these same participants commented on the (at times unexpected) positive public reaction to the 2003 legislation which outlawed smoking in bars and restaurants in New Zealand. ‘I am amazed at the people who say that they’re delighted that there’s no smoking in bars anymore.’ (Politician 6) ‘Bars are going to be smokefree in a year’s time, and everyone screamed. . .moan, moan, moan. Bang, in it came, and no moaning. One or two, but on the whole they just accept it. Then they realise, “Actually, this is bloody good.”’ (Official 9) Nor was this enthusiasm seen to be confined to nonsmokers: ‘[W]hen [bars became smokefree] lots and lots of people really loved it and. . .most smokers want to give up and so anything that reduces their consumption. . .they like it as well.’ (Politician 9) And one respondent suggested that ‘a leap of faith’ might be necessary in some policy moves: ‘[Smokefree bars have] been a phenomenal change . . . And yet [now] everybody loves it. Absolutely loves it. And so. . . you just do it. In circumstances like that.’ (Politician 10) However, it is perhaps a reflection of the perceived power of the ‘nanny state’ idea, or of over concern for preventing discord from a particular sector of society, that only one participant made the significant connection that the large majority of New Zealanders are not smokers. Accordingly, this person expected sufficient support for smokefree measures: ‘So I don’t know what the political risk is here, because the majority of people are not smokers. And the majority of people, even smokers, favour tightening up on these things so it’s only sort of civil libertarians who think it’s your right to do anything you want.’ (Official 10)
3.5. Engaging the community In contrast to the notion of compulsion by an intrusive state, which participants were largely uncomfortable with, was the suggestion that public acceptance of smokefree policy can be achieved through other, less ‘authoritarian’, means. This issue was highlighted by the interviewees who talked of the need to ‘take your public with you’ (Official 6), ‘to take people with you’ (Politician 3), ‘to change people’s mindsets’ (Official 11) or to capture ‘hearts and minds’ (Officials 1, 4). Several drew on the empowerment
discourses of community development to expand on the idea of persuasion, rather than legislation, as a strategy to get communities onside. For example: ‘[I]t’s OK that a law doesn’t necessarily get implemented instantaneously. . .a law often sows very strong seeds in a community and in people’s minds, which with time – and sometimes not that long – empowers people or enables them to implement it themselves and in not a terribly top-down way.’ (Official 8) There was a strong emphasis on the importance of community support by the majority of Pacific respondents. This was demonstrated by the frequent comments that, if they are to be effective, policies need to have community buyin, and/or be driven at a grass roots level (Officials 3, 4, 12, 13, 14, 15; Politicians 17, 18) For example: ‘[Y]ou go out to the community and you ask them what they think and . . . that is why some of the things are working, because they have developed the priorities for their community and they drive it, rather than [government] policies. . . [un]like the patronising . . . ‘You must do this’ approach.’ (Official 12) ¯ A number of Maori participants also talked about the need for community support in terms of ‘ownership: ‘The government has got to . . .put a little bit more faith in our communities that they actually know what they are doing. It gives it that good community ownership. . .Our communities. . .are able to maintain those strategies and programme themselves because they believe in it and it’s theirs.’ (Official 16) ‘I think you have got to have. . . community support and buy-in, because they’re ultimately providing the deepest reach into the homes and the households.’ (Politician 13)
3.6. Concern for smokers Interviewees mentioned the difficulties for smokers, such as addiction, a lack of resources, stress and family dysfunction or other similar concerns. One participant, at least, made it clear that this view impacted on his/her policy stance: ‘I’m ambivalent on [smokefree outdoors] ‘cos I’m sympathetic to people who. . .find it really difficult to give up. I’m sympathetic to people who. . .the stresses and strains of whose life means that they haven’t got a show in hell of giving up, and. . . the people at the bottom end of the socio-economic spectrum are absolutely caught in this.’ (Official 6) Some participants positioned smokers as the hapless victims of smokefree policies: ‘I think society’s shifting with smokers outside. . .I mean it looks bad, it’s freezing cold, you feel sorry for them, people must feel. . .like a pariah, or a leper. . .They’re out there and you see them and you think, ‘Oh, you poor thing.’ (Politician 5)
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‘I believe it’s time we brought the smokers back in, and said it wasn’t about you, it was about exposure to second hand smoke, we’re not trying to get at you. In fact, we know you need and deserve the very best support to help stop smoking, and we’re going to provide it for you. . . So do something for the smokers.’ (Official 1) One participant suggested policy solutions are influenced by the way smoking is framed in terms of responsibility and blame: ‘[Y]ou always have to frame [smoking as] an addiction. So you have diminished responsibility because of that addiction. . . it’s about reframing it . . . and the way we are doing it is taking the responsibility away from the individual by actually. . . blaming someone else, and that’s the tobacco industry.’ (Official 9) The perception of the tobacco industry as an underlying problem was relatively uncommon in the data. However, some participants identified the industry as an obstacle to smokefree policy change: ‘There’s . . . a proportion of smokers who feel that there’s enough restrictions already, and don’t want government to intrude anymore. The industry itself is obviously going to be supportive of any people who want to take a stand [on this argument].’ (Official 12) ‘They’re very powerful. Tobacco, alcohol, gambling, all those lobbys are extremely powerful, and extremely well connected. Very difficult . . . They’ve got more money.’ (Official 16) Part of the lack of policy emphasis on the industry was seen as due to their low public visibility: ‘The visible industry in NZ is actually the local dairy [corner shop].’ (Official 4) 4. Discussion Policy activity around smokefree areas was seen by interviewees as a highly politicised activity, involving the difficult and constant balancing of a number of competing interests, motivations and demands. Although we have identified five main themes, this is not to imply that they represent consistent or clearly fixed views or positions of participants. On the contrary, there were discontinuities and contradictions within and across texts, reflecting the fraught and fractured nature of the policy process. 4.1. The role of evidence for smokefree policy It has been argued that ‘because social science is merged with other knowledge, officials. . .have great difficulty disentangling the lessons they have learned from research from their whole configuration of knowledge’ [4]. If this is the case, the absence of a clear linear progression from research to policy does not necessarily indicate a lack of rationality in decision-making [4,29]. However, while the need for evidence to inform policy was woven to varying degrees through the data here, the findings suggest that policymaking for tobacco control is
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a process in which research plays only a relatively small part, when weighed up against a number of other, often highly political, imperatives, such as the need for public acceptability and community engagement to avoid political repercussions. This is consistent with research in the United States which found that the most powerful forces affecting the policy agenda were perceptions by policymakers of a ‘national mood’ and electoral fall-out [6]. It is also consistent with the rejection by many New Zealand politicians during 1997–2005 of evidence about secondhand smoke hazards [16]. There are a number of ways in which these perceptions of policymakers may be flawed. As Kingdon says, the ‘national mood does not necessarily reside in the mass public, but instead is perceived in the attitudes of various active sectors of the public’ [6] (p. 162). For instance, the ‘nanny state’ concerns of the New Zealand public about new smokefree policies may have been overstated by the interviewees. Recent research has found strong support in New Zealand by both non-smokers and smokers for extending some smokefree initiatives [19,20,30,31]. However, the perception of public opposition has particular implications for proponents of change to smokefree areas. The political onus usually lies with these advocates, if they are to avoid claims of state interference, to demonstrate that there is public support for what might be considered unacceptable changes. There are exceptions. The comments by some participants that the smokefree bars and restaurants policy was very popular afterwards, despite mixed support at the time of change, are supported by research [18]. This suggests that there is scope for politicians and policymakers to take a more leadership type of approach when making new smokefree policy. 4.2. Concern for smokers versus children The concern for smokers illustrates the complications in devising policies to protect children from being exposed to secondhand smoke and to the role modelling impact from seeing adult smoking. If people are seen to be victims of poverty, stress, or nicotine addiction, it may appear heartless to promote substantive policies which may make their lives even harder. The concern can mean that the focus of policymaker concern is with smokers rather than children (even when the latter are more vulnerable and have very constrained choices). The concern does not even seem to factor in the benefit for smokers who quit or cut down, as a result of smokefree areas. However, these feelings may ignore or obscure smoker support for change. For example, recent research found that over 90% of New Zealand smokers from all socio-economic and ethnic groups supported the banning of smoking in cars with small children [19]. There is also evidence that, in contrast to the view of entrenched smoking behaviours among certain groups, different ethnic and socio-economic groups can respond equally well to quit campaigns [32]. The relative inability of policymakers to see the tobacco industry as responsible for the effects of smoking is evident in other studies of tobacco control policy [33], although sometimes immediate political necessity has obscured even the question of responsibility [8,34]. ‘Concern about
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smokers’ and about other groups is a traditional industry strategy to deflect policy attention from its responsibility [35,36]. 4.3. The impetus for community engagement and leadership It has been said of smokefree policymaking that governments must ‘sense the degree to which the public will follow’ [37]. The study findings, with the emphasis on public acceptability and community engagement, highlight participants’ concern to get public support for proposed smokefree policies. This is also reflected in the preference of many of the interviewees for persuasion rather than legislation, as a means to achieving further smokefree areas. The community engagement focus appears consistent with the argument that the traditional public health discourse, in which there are victims and culprits, is less meaningful today. Instead, contemporary health promotion may avoid intervening, coercing or punishing, by working ‘at a distance’ through collaborative ventures, lobbying for policy change, and promoting community action or community development [38]. This notion of community development underpins the growing emphasis in New Zealand policy documents and statements on community participation and partnership in decision-making, particularly in health [39–44]. Although in practice these concepts may be little more than rhetoric, it is perhaps a reflection of their currency in the New Zealand political arena that they resonate so strongly in our interviewee data. However, in the context of tobacco control, this approach may merely mask a convenient shifting of responsibility for action from government to local communities. In other words, community engagement can be seen as a preferable way to effect individual behaviour change around smoking, while avoiding national-level policy decisions which policymakers anticipate will be unpopular. The question of what should be ‘leadership’ in smokefree policy was implicitly or explicitly raised by interviewees (and is debated in the policy literature) [45]. Letting local leaders drive local policy was clearly attractive to national-level policymakers (as long as there were little negative consequences for them), as there were advantages for communities (more local control) and also for the national level (less heat on national policymakers from objectors to policies). ‘Top-down’ has dangers of unpopularity and non-implementation [46]. A rarer response was that national leadership was needed to get smokefree policies into place, as these would then be appreciated for their benefits by a public, some of whom had been sceptical. 5. Policy implications The wider health sector cannot assume that policymakers have an accurate or rational view of public support for smokefree policies. Policymaker perceptions of these factors may need to be adjusted towards the available evidence, in order to provide some balance to personal experiences and political pressures. However, because of
the complex nature of policymaking, evidence of health effects or support will be only a part of the mix used in the decision processes. Evidence of policy effectiveness in some settings is not necessarily relevant to other settings, due to the local politics and practicality of implementation. Assumptions of the primacy of ‘evidence-based’ policy does not take into account the personal aspects of the policy process, and ‘the mismatch of randomized thinking with nonrandom problems’ [47]. For tobacco control policy, there are further inherent challenges to evidence-based policymaking, including ‘the integration of complex and sometimes conflicting information from authoritative sources’, and ‘the importance of individual versus governmental responsibility’ [48]. While community participation in decision-making may be useful for the local implementation of policy and development of services, it is arguably less prudent for some policies. These include smokefree car laws, which probably require a state or national legislative approach to ensure all disadvantaged and vulnerable groups benefit. While persuasion may always play a part in the policy process, at times the onus is on policymakers to follow logic and available evidence to take a leadership role in protecting public health. As Rein says, ‘Any choice of policy is risky—full of uncertainties and unforeseeable consequences: at some point we have to commit ourselves for better or worse’ [49] (p. 19). How can the complexities of policymaking be navigated to achieve change? We know that some sorts of evidence are particularly attractive for policymakers. Putting numbers to deaths or other tangible outcomes so to make issues more concrete, and giving human faces to issues, helps cut through complexity [16]. Creating a resonant narrative from research evidence means that the evidence can be more persuasive [50,51]. When the evidence narrative clearly offers solutions to policy problems, it is more likely to draw policymaker attention [52]. In order to strengthen the resonance of smokefree policy narratives, mass media coverage of smokefree issues (paid and unpaid) may provide an effective, if longer term, foundation for positive change [10,53]. The New Zealand smokefree media campaigns have provided policymakers with a common series of narratives which they can discuss and argue from with each other, and with the public [21–24].
6. Limitations This case study was limited by the incomplete response rate from officials and politicians who were approached for interviews. Another limitation was the time constraints for some of those who were interviewed, which meant there was less opportunity to explore some of their responses in-depth. Nevertheless, given the amount of repetition of common themes, we are confident that the major attitudes held by of these policymakers were captured in this study. The anonymity of the interviews generally enabled far more candid statements compared to those made in public.
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7. Conclusions Policy activity around tobacco control is considered by New Zealand policymakers and politicians as a balancing act, influenced by a number of competing factors. The political acceptability of policy was seen as paramount, largely outweighing the impact of evidence or other considerations. As a result, most participants preferred a policy approach involving persuasion rather than legislation, underpinned by strong community engagement. As elsewhere, advocates have a continual need to communicate the acceptability of smokefree changes which require legislation to be optimally effective. Acknowledgements The Health Research Council of New Zealand funded this project (the Smokefree Kids Project). We thank Sheena Hudson, Tolotea Lanumata, Linda Tasi-Mulitalo and Kiri Parata who conducted most of the interviews. We also thank our interviewees. Dr. Nick Wilson gave very helpful comments. References [1] Bulmer M, Coates E, Dominian L. Evidence-based policy making. In: Bochel H, Duncan S, editors. Making policy in theory and practice. Bristol: Policy Press; 2007. p. 87–102. [2] Chapman S. Public health advocacy and tobacco control: making smoking history. Oxford: Blackwell Publishing; 2008. [3] Lindblom C. The science of “muddling through”. Public Administration Review 1959;19:79–88. [4] Weiss C. Policy research in the context of diffuse decision making. Journal of Higher Education 1982;53:619–39. [5] Burton P. Modernising the policy process: making policy research more significant? Policy Studies 2006;27:173–95. [6] Agenda KJ. Alternatives and public policies. New York: Longman; 2003. [7] Popay EH. How are policy makers using evidence? Models of research utilization and local NHS policy making. Journal of Epidemiology and Community Health 2000;54:461–8. [8] Bryan-Jones K, Chapman S. Political dynamics promoting the incremental regulation of secondhand smoke: a case study of New South Wales, Australia. BMC Public Health 2006;6(192), doi:10. 1186/14712458-6-192. [9] Freeman B, Chapman S, Storey P. Banning smoking in cars carrying children: an analytical history of a public health advocacy campaign. Australian & New Zealand Journal of Public Health 2008;32: 60–5. [10] Chapman S, Wakefield M. Tobacco control advocacy in Australia: reflections on 30 years of progress. Health Education and Behavior 2001;28:274–89. [11] Cohen J, de Guia N, Ashley M, Ferrence R, Northrup D, Studlar D. Predictors of Canadian legislators’ support for tobacco control policies. Social Science & Medicine 2002;55:1069–76. [12] Andersen PA, Buller DB, Voeks JH, Borland R, Helme D, Bettinghaus EP, et al. Predictors of support for environmental tobacco smoke bans in state government. American Journal of Preventive Medicine 2006;30:292–9. [13] Malone R. Rebalancing the constitution: the challenge of government law-making under MMP. Wellington: Institute of Policy Studies; 2008. [14] Howes M, Lyons K, Bryant S. Civil society revisited: possibilities for increasing community collaboration in a competitive world. In: Australasian Political Studies Association Conference. 2004. [15] Roper B. Business political activity in New Zealand from 1990 ¯ to 2005. Kotuitui: New Zealand Journal of Social Sciences Online 2006;1:161–83. [16] Thomson G, Wilson N, Howden-Chapman P. The use and misuse of health research by politicians during the development of a national smokefree law. Australia and New Zealand Health Policy 2007;4:24.
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