Translating research evidence into policy: Tobacco control policymaking in Lebanon

1. Translating research evidence into policy: Tobacco control policymaking in Lebanon Rima Nakkash, DrPH Assistant Professor Health Promotion and Community Health Faculty of Health Sciences American University of Beirut January 30, 2013

2. 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

3. 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

4. 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

5. The Policy PIE “The RM Knowledge Translation Toolkit: A Resource for Researchers”2008

6. A piece of the pie AUB Tobacco Control Research group • 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

7. 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.

8. The Evidence • Warning labels • Advertising and marketing restrictions • Secondhand smoke restrictions • Taxes • Cessation and prevention activities • Education

9. 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.

10. Tobacco Control Policy in Lebanon : From 1970 to 1993 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." Advertising ban on “STATIONARY ITEMS, BILLBOARDS, LUMINOUS SIGNS, ETC .” Decree NO.3 of 9/12/1976. Circular to ban advertising, in Cinemas and on the T .V. Decree Health warning No.213/1 10.4.80 on packs, specified 10%, and HW : TV advertisements and on packs Nic/tar limitations proposed HW: Smoking is the main cause of lung cancer, cardiovascular diseases and arterial diseases. Administrative decision - ban smoking in hospitals , dispensaries, pharmacies, cinemas, theatres , public transportation , sports clubs, classes in schools , universities and in elevators Passage of Law-HW on packs and advertisements HW:“Ministry of  Public Health warns you about smoking dangers” Following decree specifying 10% Proposed law to amend 1983 number 101

11. Tobacco Control Policy Making in Lebanon From 1993 to present date 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. 1993

12. Tobacco Control Policy Making in LebanonYear 2003 Jan 24 Mar 19 Mar 31 April May 22 Jun 9 Sept 30

13. Year 2004 May Jul 14 Jul 28 Aug 5 Jan Mar Sept 13 Dec 1

14. Year 2005 Jan 26 Feb 4 Feb 17 Nov 24 Dec7 Dec8 Dec 21 Dec 1

15. Tobacco Industry Interference in Tobacco Control Policy making 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.

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

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

20. So what’s the story?

21. Where we were and where we wanted to be …. A - 2009 No FCTC compliant tobacco control policy B- FCTC compliant legislation

22. 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

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

24. 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.

25. Research to policy gap • What additional research do we need to expand the local evidence base? • What sort of knowledge is needed ?

26. Disseminate policy relevant and timely research to support needed policy changes Smoke free policies Tobacco industry influence Economics of Tobacco Health Warnings Waterpipe health effects, prevention , intervention , and policy implications

27. Year 2010 Jan Feb Press Conference and launching of a media advocacy campaign

28. 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.

29. 2-Discrediting the Tobacco Industry

30. 3- Lobbying parliamentarians

31. Year 2010 Feb Jul -Sep Jan Mar Apr May Nov Jun Petition Press Conference and launching of a media advocacy campaign Off Press conference on economics of tobacco control WNTD Reception and launch of petition

32. Approved final version to be discussed for voting Year 2011 • Attended all parliamentary sessions • Amended an article at the last minute of voting NEW PHASE Feb June/July Jan March April August September May WNTD Training of Lawyers Off Published in the national gazette

33. 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.

34. 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

35. 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 • 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. • 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.

36. 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

37. 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)

38. 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

39. 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

40. 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

41. THANK YOU