Policy Underreaction and Noncommunicable Diseases: Why Did It Take Decades for Governments to Move from Promotion to Control of Tobacco and What Does It Portend for other NCDs?

Background: Worldwide, non-communicable diseases (NCDs) account for over 60% deaths per year. Campaigns against NCDs' risk factors, including tobacco and obesity, occur at multiple levels of governance. We aimed to use a five-factor model for explaining tobacco policy to theorize and measure policy underreaction, clarifying conditions that led to initial lack of policy response to tobacco hazards, how policy resistance was overcome, and lessons for other NCDs' risk factors.

Methods: We utilize a mixed-methods approach by drawing on secondary data and triangulating that with archival documents and several years of interviews. We compare WHO best practice recommendations with action by governments of Western democracies to identify lessons tobacco provides for addressing other NCDs' risk factors.

Results: Tobacco policy in Western democracies is an example of almost universal underreaction by governments for an extended period, but it fits uneasily with most explanations offered for policy change.  The ‘critical juncture' on which change may have hinged was reports by UK College of Physicians (1962) and US Surgeon General (1964). Yet most governments did not move from a political economy framing to a health promotion framing until decades later, which was facilitated by shifts in institutions, agendas, networks, socio-economic factors, and ideas. 

Conclusion: Tobacco use has declined in Western democracies with shift from political economy to public health framing. This has been hailed as a major public health triumph and an example of a substantial policy change, perhaps worthy of emulation on other NCDs' risk factors such as obesity. We examine this possibility.