Translating research evidence into policy:

Tobacco control policymaking in Lebanon

Rima Nakkash, DrPHAssistant Professor Health Promotion and Community HealthFaculty of Health SciencesAmerican University of Beirut

January 30, 2013

Overview •Background

What we mean by translating research into policy Overview of TC policy status in Lebanon

•Tell the story Process of informing policy formulation Evidence used Overview of the advocacy strategies

•Barriers, facilitators, and lessons learned•Preliminary findings from a qualitative

evaluation

Acknowledgment•Civil Society partners , especially TFI and

Indyact•Supportive media,parliamentarians, and

other policymakers• Issam Fares Institute for Public Policy and

International Affairs•Colleagues in my department, faculty, and

all TCRG members •President Dorman•Communication office at AUB

What is knowledge translation ?

“the exchange, synthesis and ethically-sound application of research findings within a complex set of interactions among researchers and knowledge users…

…knowledge translation can be seen as an acceleration of the knowledge cycle; an acceleration of the natural transformation of knowledge into use.”

IDRC-Research matters,2008

The Policy PIE

“The RM Knowledge Translation Toolkit: A Resourcefor Researchers”2008

AUB Tobacco Control Research group

A piece of the pie•Health Promotion and Community Health•Health Management and Policy•Engineering•Pathology and Laboratory Medicine•Nursing School•Issam Fares Institute for Public Policy and International Affairs•Epidemiology and Biostatistics•Chemistry•Economics

The Framework Convention on Tobacco Control

 Adopted in May 2003 by the World Health Assembly (WHA). Ninety days after the 40th country ratified the treaty, the FCTC became legally binding in February 2005.Over 170 countries ratified.

The Evidence

• Warning labels

• Advertising and marketing restrictions

• Secondhand smoke restrictions

• Taxes

• Cessation and prevention activities

• Education

Overview of TC policy status in Lebanon- Sources of Data

• Comprehensive review of the archives of two daily newspapers with highest circulation figures (Al Safir and Al Nahar) from 1974 to 2006.

• 2340 tobacco industry documents for Lebanon and the Middle East retrieved and reviewed a total number of documents used in between 450 and 500.

• Drafts of proposed laws concerning the tobacco sector, official correspondence between ministries and Council of Ministers offices, texts of proposed laws and regulations, Lebanese parliament official newsletters, index of tobacco-related laws, and reports from the national tobacco control program provided by key informants.

Circular to ban

advertising, in Cinemas and on the

T .V.

Advertising ban on “STATIONARY

ITEMS, BILLBOARDS,

LUMINOUS SIGNS, ETC .”

Decree NO.3 of 9/12/1976.

Decree No.1/174 of Decree to impose HW on advertisements,

broadcast, TV. or print-no size stipulated

HW: "The Lebanese Ministry of General

Health warns you from the hazards of

smoking."

Decree Health warning No.213/1 10.4.80 on packs, specified 10%, and HW : TV

advertisements and on packs

Nic/tar limitations proposedHW: Smoking is the main

cause of lung cancer, cardiovascular diseases and

arterial diseases.

Passage of Law-HW on packs and

advertisementsHW: “Ministry of 

Public Health warns you about smoking

dangers”Following decree specifying 10%

Proposed law to

amend 1983 number 101

Administrative decision - ban

smoking in hospitals , dispensaries,

pharmacies, cinemas, theatres , public

transportation , sports clubs, classes in

schools , universities and in elevators

Tobacco Control Policy in Lebanon : From 1970 to 1993

Passage of Law-HW on packs amending 1983 Law number 101. HW: “Ministry of Health warns: Smoking leads to dangerous and deadly diseases.”

-Bill proposed to introduce a minimum age 16 to buy tobacco products  -Bill proposed to ban smoking in government places

-Administrative Decision or decree -Public ban in government offices -Proposed Law to ban advertising presented to Council of Ministers and refused.

 

Tobacco Control Policy Making in Lebanon From 1993 to present date

1993

Jan 24 Mar 19

Mar 31 April May 22

Jun 9 Sept 30

Tobacco Control Policy Making in LebanonYear 2003

Jan Mar May Jul 14

Jul 28Sept 13

Dec 1

Year 2004

Aug 5

Jan 26 Feb 4 Feb 17 Nov 24

Dec 1 Dec 8 Dec 21

Year 2005

Dec 7

A barrier to moving foreword …..

“Nicotine is addictive. We are, then, in the business of selling nicotine…” (Addison Yeaman from Brown & Williamson, 17 July 1963)

Tobacco company CEOs declare, under oath, that nicotine is not addictive (1994) –in court.

Tobacco Industry Interference in Tobacco Control Policy making

16

Multinational cigarette companies impose their influence on Lebanon

•On the 10th of April 1980 the Minister of Health, Talal El-Merhabi, proposed decree No. 213/1, “Publicité pour les Cigarettes,” requiring a health warning be placed on 10% of a cigarette pack surface, and on all television and billboard advertisements, stating, “Fumer est une cause majeure du cancer de la maladie des poumons, la maladie et des artères.” [i]

[i] Www.pmdocs.com , Philip Morris, April 10, 1980, 1000145696 - 5697.

[ii] Www.pmdocs.com , Philip Morris, April 17, 1980, 1000145698.

17

Policy Influence•Five days later Philip Morris’s advertising

agent paid visits to high level policy makers….

He let them know that it would be “taking a huge risk [to] determine that smoking is a direct cause for any disease,” …..

Moreover, “The prompt execution of the decree...would give way to transfer of pan Arab advertising to other countries.” [ii]

18

Smoking and Health?

•MacLeod kept up the pressure, asking for a file of documents on smoking and health that would “include scientific information, which can be used against qualified medical opinion from the Lebanese Ministry of Health.” [i]

[i] Www.pmdocs.com , Philip Morris, June 17, 1980, 0000137936

http://www.emro.who.int/TFI/Voice%20of%20Truth%20ARABIC.pdf

So what’s the story?

Where we were and where we wanted to be ….

A - 2009 No FCTC compliant tobacco control policy

B- FCTC compliant legislation

In 2009 the policy under discussion was poorly informed by research evidence

•Smoking/nonsmoking sections•Loopholes-restricted places were ban is

active•Long and gradual implementation delays• Partial bans of advertising (sampling

under 18,point of sale, relationship marketing and direct. Up to three-5 year proposed delays

•HW’s textual and 30%•Unclear penalty and fine system

Two year intensive campaign focused on use of evidence•Parliamentarians•Civil society •Media

Our objectives

•Introducing evidence regarding effectiveness of policies.

•Having tobacco control issues discussed and discussed differently

•Discrediting the tobacco industry and its allies

•Bringing credible, and different voices into the debate (civil society and academia)

(adapted from Simon Chapman’s presentation on advocacy)

…Having a law that is evidence-based and not just any law.

Research to policy gap

•What additional research do we need to expand the local evidence base?

•What sort of knowledge is needed ?

Smoke free policies

Health WarningsTobacco industry influence

Waterpipe health effects, prevention , intervention , and policy implications

Disseminate policy relevant and timely research to support needed policy changes

Economics of Tobacco

Jan

Year 2010

Feb

Press Conference and launching of a media advocacy campaign

Excerpt from the position statement issued in February 2010

We consider the following three measures the cornerstone of a sensible and effective tobacco control policy:•Total bans of smoking in indoor public places without exemptions and without permission for smoking and non-smoking areas.•Total comprehensive advertising bans, both direct and indirect (including promotion, branding, etc.)•Large pictorial health warnings on tobacco products at least 40% on two larger surfaces of the pack with rotating messages every six months to avoid wear-out.

We outline here an explanation of why these must be adopted and why half-measures should not be allowed.

2-Discrediting the Tobacco Industry

3- Lobbying parliamentarians

Jan Mar Apr Jul -SepNov

Year 2010

MayFeb

Press Conference and launching of a media advocacy campaign

Jun

Petition

Press conference on economics of tobacco control

Reception and launch of petition

OffWNTD

Jan March April September

Year 2011

June/July

Feb

August

Approved final version to be discussed for voting

Off Published in the national gazette

NEW

PHASE

May

WNTDTraining of Lawyers

• Attended all parliamentary sessions

• Amended an article at the last minute of voting

Law No. 174

• Total bans of smoking in indoor public places without exemptions and without permission for smoking and non-smoking areas.

• Total comprehensive advertising bans, both direct and indirect (including promotion, branding, etc.)

• Large pictorial health warnings on tobacco products at least 40% on two larger surfaces of the pack with rotating messages every six months to avoid wear-out.

Breakthroughs

• New supportive group of MP’s• Increased coverage by media • Harmony in collaboration/partnership with civil society• Use of research through policy briefs ,papers, etc..• Altered articles in the law closer to informed best evidence• Putting the Tobacco Industry under close watch

Barriers and facilitators to success

Barriers•Tobacco industry interference in Parliamentary Committee meetings and with allies •Competing sources of information - doubting credibility•Difficulty accessing some policymakers•Prolonged discussions and changing opinions•Time intensive face to face lobbying •Limited human and material resources

Facilitators•Civil society authority, and commitment to the cause•Media support•Credibility of scientific evidence•Close Collaboration with the National Tobacco Control Program•Shared purpose and common messages and supporting arguments.

• Advertising sector livelihood

• Hospitality sector losses

• Tourism industry damage

• Other countries started gradual implementation why do we have to be so radical

• Lebanon is different.

Evaluating the role of academics in advancing tobacco control policy in Lebanon• Semi-structured interviews with key stakeholders in the

policymaking process -May to September 2012• Interviews with Media, Civil society, and policymakers

Value of partnerships“Ministers, the way I see it, respect academics and

get scared of the media. That is why we should have the academics and media working together. This somehow took place in the tobacco campaign to set the law, where both academics and media were using the same language to talk about the same cause. The result was to put the right type of pressure….”(journalist)

Credibility and accountability to the policy making process

“The information is coming from academics; it is complete, objective and based on facts. These academics have the necessary information, and they can provide information about other countries' experiences. This brings all necessary information into the drafting of the law.”

Parliamentarian

Academicians gain the trust of people“A journalist or an NGO can lobby for anti-smoking but at

the end of the day they do not have the facts as an academician does. An

academician gives credibility to the topic when giving facts, and this helps in convincing lay people and decreases the chances of facing resistance from tobacco companies and the smokers who know that smoking is harmful.”

Civil Society

“I cover a thousand topics, if I don’t have academics that are experts in those topics, who can I get these information from? I can keep on writing that smoking is not good for people’s health, but if I don’t have statistics and studies done about this topic I can never convince people and gain their trust. But if I add those

numbers and write about those studies, my story becomes credible.”

Journalist

Acknowledgment•Civil Society partners , especially TFI and

Indyact•Supportive media,parliamentarians, and

other policymakers• Issam Fares Institute for Public Policy and

International Affairs•Colleagues in my department, faculty, and

all TCRG members •President Dorman•Communication office at AUB

THANK YOU