Elsevier

Social Science & Medicine

Volume 67, Issue 11, December 2008, Pages 1679-1689
Social Science & Medicine

Health promotion research and practice require sound policy analysis models: The case of Quebec's Tobacco Act

https://doi.org/10.1016/j.socscimed.2008.07.028Get rights and content

Abstract

In this paper we illustrate how policy analysis models can deepen our understanding of the challenges facing health promoters advocating for policy change. Specifically we describe the factors underpinning the adoption of Québec's Tobacco Act (1998) and the role played by actors from governmental public health agencies (GPHAs). Data were collected through interviews (n = 39), newspapers articles (n = 569) and documents (n > 200) from GPHAs, NGOs, the Québec National Assembly, and opponents to the legislative measures. Data collection and analysis were based on Sabatier and Jenkins-Smith's Advocacy Coalition Framework (1999) and Lemieux's theorization of coalition structuring (1998). We explain the adoption of the Act by: (1) the broad recognition within the policy elite of the main parameters of tobacco use (i.e. lethality, addictive properties, and legitimacy of governmental intervention), (2) the impacts of a series of events (e.g. cigarette contraband crisis) that enabled tobacco control advocates to influence public debates, and the governmental agenda, (3) the critical contribution of a coalition of GPHAs pooling resources to address both the sanitary and economic aspects of the legislation while countering the opposition's strategy, and (4) the failure of the opponents to present an unified voice on the definition of the tobacco policy. This study illustrates the merits of applying a policy-change model to grasp the complexity of the process. Our findings call for the development of permanent policy analysis capabilities within public health agencies and for a broader scrutiny of the non-health-related dimensions of policy debates.

Introduction

Despite repeated calls for strategies to foster healthy public policies (Oliver, 2006, WHO, 1986, WHO, 1988), policy analyses in health promotion still present many challenges that prevent public health systems from learning from past experiences and effectively advocate for state intervention. One limitation raised by Catford (2006) is that health promoters have so far devoted little attention to the policy change and decision-making processes leaving practitioners with little guidance in their advocacy enterprise. Moreover, most accounts of policy processes in the public health literature remain largely a-theoretical (de Leeuw, 2001) and are thus not easily amenable to drawing lessons for future advocacy. For instance, while writings on public policy intervention in health promotion stress the importance of media advocacy to foster policy change, most are oblivious on how this instrument integrates into or interacts with the global policy making process (for an example, see Chapman & Dominello, 2001). The situation cannot be explained by a lack of models of the policy process. Political scientists have been developing models for as much as fifty years (see for instance, Baumgartner and Jones, 1993, Kingdon, 1984, Ostrom, 2007).

Considering the state of policy research in health promotion, it appears necessary to look at the merits of integrating sound policy analysis models within policy advocacy practice and research. In order to fulfil this goal, we analysed a successful advocacy intervention strategy spearheaded by a coalition of governmental public health agencies (GPHAs) in support of a bill to tackle the tobacco problem in the Province of Québec (Canada). The Tobacco Act aims were to restrict the promotion and sale of tobacco products (e.g. ban on the sponsorship by the tobacco industry of arts and sports events, ban on sale in drugstores, prohibition of sales to minors) and to protect non-smokers and workers from ETS. In addition, the Act also asserts the right of the government to legislate on the composition and on the packaging of tobacco products.

In this article we report on our approach by presenting the results drawn from two specific objectives of this case study, i.e., identifying:

  • the factors and processes explaining the adoption of the Tobacco Act and;

  • the contribution of the GPHAs in the adoption of the Act.

In what follows, we will first present the two components of our model and a brief description of our method.

This project was guided by two theoretical contributions from political science. Sabatier and Jenkins-Smith's (1999) Advocacy Coalition Framework (ACF) provided guidance on the policy change process while Lemieux's (1998) theory on coalition structuring was applied to identify the challenges/constrains and strategies of actors trying to influence the policy process by pooling some of their resources.

Paul Sabatier and Hank Jenkins-Smith propose the ACF to explain the emergence of and changes in public policy. They maintain that policies are the product of the belief systems of the actors concerned by a given policy subsystem, here the tobacco subsystem. Such actors not only include legislators, civil servants and the representatives of interest groups but also other actors concerned by the problem in question, such as journalists and academics. All of these actors make up the policy elite of the subsystem.

Policies emerge from numerous confrontations and negotiations between different coalitions of actors in the subsystem (see Fig. 1). Each coalition forms around a belief system that conveys a worldview and its own hierarchy of values.

In the policy subsystem, one coalition typically predominates by imposing its vision of problems and solutions; a vision compatible with its belief system. This coalition enjoys important strategic advantages from the standpoint of resources and opportunities. According to the model, the accumulation of new knowledge and the struggle waged by one or more challenger coalitions can achieve only limited policy change, i.e., modifications in the secondary aspects of the policy. Only events outside the subsystem are likely to significantly upset the coalitions' advantages and resources. These events (see Fig. 1) allow one challenger coalition to impose the policy core of its belief system. It can do so by changing, for instance, the rules, resources and individuals in charge of institutions and through the adoption of legislations imposing its own vision of the problems and solutions. Such being the case, Sabatier and Jenkins-Smith believe that external events are a necessary but insufficient condition to change the policy core attributes of a governmental program or policy. The challenger coalition must usually mobilize its resources to take advantage of the opportunities stemming from such events.

Lastly, Sabatier and Jenkins-Smith note that the decisions underlying policies are determined in part by a series of parameters, e.g., basic attributes of the problem area, fundamental socio-cultural values, and so on that are highly stable over time and over which the coalitions exercise virtually no control. Such parameters are, in fact, contextual variables that establish the realm of possibilities surrounding the discourse of the coalitions. They thus have a constraining effect on the nature and outcomes of policy debates.

But as noted by other authors (Mintrom and Vergari, 1996, Schlager, 1995, Schlager and Blomquist, 1996), the ACF falls short of providing a satisfactory explanation on how conditions leading to policy oriented collective action take place and on how disputes between actors are prevented and resolved to secure an alliance. We have applied Lemieux's theorization to guide our analysis of the problems and rationales behind collective bargaining for the pursuit of a common policy goal.

For Vincent Lemieux (1998), whose theory is based on Gamson's (1961) seminal paper, organisational and individual actors set up coalitions either as a way to respond to a looming threat from the policy environment (e.g. cuts in a governmental program or budget) or to seize an upcoming opportunity to achieve their goal as will be illustrated in this paper. Therefore, coalitions are set up as a result of the members' assessment of their policy environment.

This assessment is an ongoing process which determines three key dimensions of the coalition including transactions, relationships and controls. First, the transactional dimension refers to the cost–benefits analysis members of coalition continuously operate prior to and while partaking in the coalition. Costs of enrolment in the coalition and the nature of the risks involved are assessed against the potential benefits that can be obtained through collective efforts. If a change in the policy environment significantly increases the enrolment costs or level of risk, some or all coalition members may decide to withdraw or renegotiate their share of resources invested in the coalition.

The second dimension of a coalition refers to the relationships between the members. Lemieux posited that a coalition made of actors sharing affective and ideological affinities is more likely to last and sustain hardship than an alliance made of actors with little previous experience of collaboration and who have not developed the mechanisms to resolve the conflicts likely to occur.

The last dimension refers to the controls. By controls is meant the power structure that allows the coalition to mobilize and put its resources to use in order to dominate its environment. Because enrolment in a coalition, as defined by Lemieux, is on a voluntary basis, members generally have an equal say in decision-making and equal access to critical information. However, and as the policy environment of the coalition evolves, the coalition may be challenged by an upcoming threat to its goal to which its power structure cannot respond satisfactorily (e.g. a decision-making process too slow to face fast-evolving situation). As a result, coalition members may opt to relinquish some of the control they exercise over the day-to-day activities of the coalition to a more centralized decision-making body, thus allowing for a better hold on coalition resources.

Coalitions in the sense of Lemieux are thus temporary strategic alliances intended for a specific goal. This contrasts with Sabatier and Jenkins-Smith's advocacy coalitions which are broader in terms of constituency, are made of actors sharing a common set of policy beliefs and can evolved over a long period of time. This implies that as one analyses the evolution of an advocacy coalition over a number of years, s/he might witness the rise and fall of different strategic alliances forged to either actualize specific goals of the advocacy coalition or to secure its hold on the policy subsystem.

Section snippets

Method

For this qualitative study, we applied a case study design (Stake, 1995). Sabatier and Jenkins-Smith assume that the analysis of a change in public policy requires scrutinizing its policy subsystem over a period of at least a decade. We have thus delineated over time our unit of analysis, the tobacco policy subsystem, in order to examine changes that have occurred between 1986, when the first provincial statute governing the use of tobacco was adopted, and 1998, when the Tobacco Act was adopted.

The relatively stable parameters framing the policy debates

Fig. 2 summarizes the results of our analysis of the parameters and of their influence on the policy elite making up the tobacco policy subsystem. We labelled these parameters as “relatively stable” since they had already permeated, and were part of, the mainstream policy discourses as far back as 1986.

From Fig. 2, it is readily observable that 12 years prior to Québec's Tobacco Act the two basic attributes of tobacco use (i.e. its lethality for smokers along with its addictive properties) were

Discussion

We intended to demonstrate the merits of a theoretically grounded approach to policy analysis in health promotion. Applying the ACF along with Lemieux's theorization of coalition structuring, we develop a more intricate explanation of the adoption of Québec's Tobacco Act and of the contribution of the GPHAs than what would have been achievable without their theoretical insights. Whereas most studies only set their attention to the few years preceding the adoption/implementation of a specific

Acknowledgments

The Social Sciences and Humanities Research Council of Canada, through the Canadian Tobacco Research Initiative (SSHRC Grant # 834-2002-0003), funded this research project. During this study, Eric Breton was the recipient of a doctoral research award from the Canadian Institute of Health Research (NST-42826). This paper was written while he was a Social Sciences and Humanities Research Council of Canada postdoctoral fellow (#756-2005-0489 02). Lucie Richard is a FRSQ Scholar (#23187-2192). The

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