Overview
England, Australia, and the United States of America (US) share a liberal democratic tradition, and they have adopted broadly similar approaches to reducing the public health toll of cigarette smoking since the 1960s. By the twenty-first century, these countries had achieved dramatic reductions in smoking prevalence by introducing tobacco control policies that included increased cigarette taxes, restrictions on tobacco promotion, smoke-free public spaces and workplaces, and public education campaigns to encourage smokers to quit and to discourage non-smokers from smoking.
In the early 2000s, all three countries confronted a new common challenge in deciding how to respond to the emergence of e-cigarettes. Despite their common objective, each country pursued a different approach to regulating these new products. All did so in the name of public health, and all appealed to the concept of ‘evidence-informed policy’ in pursuing their individual policies.
A team of historians and social scientists from England, US and Australia have examined how these countries came to adopt different policies on e-cigarettes. In England, the use of e-cigarettes has been officially endorsed as a mode of smoking cessation and as a harm reduction alternative to smoking for existing smokers, although not without considerable controversy. Australia has banned the sale of nicotine-containing e-cigarettes to those without a medical prescription. In the US, most of the public health establishment asserted that e-cigarettes threatened the forty-year battle to end smoking.
The research team explored the history of the tobacco / smoking issue across the three countries. By examining the different ways in which supposedly value-free evidence was used within the policy process, they identified structural and political features that help to explain the effectiveness or otherwise of different policies to reduce the harms caused by smoking.
Key evidence
International and interdisciplinary evidence has been particularly valuable in providing insights into the policy process and in understanding which policies may work, where and why. The comparative approach adopted by the researchers to investigate e-cigarette policy involved a combination of the methodologies of historians and policy analysts. Documentary sources were used to track the history of the debate in each country, drawing on major reports and policy statements and on public statements made by leading public health bodies and non-governmental organisations. The arguments presented in the media and top medical journals in each country were analysed, together with key informant interviews, which had been conducted with leading figures in England and US, to understand their perspectives on policy change and evidence.
Evidence and values intersected in different ways in each of the countries, producing diverse responses and constellations of arguments to justify them in specific national contexts and histories. The resulting analysis emphasised the pre-history (a term used to identify the historical precursors) of the policy issues raised by e-cigarettes.
Policy context
The research team drew out eight key features of policymaking across the three countries, which have led to differences in policy outcomes for e-cigarettes.
- The nature of the state: England is a highly centralised nation where, once policy had been decided at the centre, it became a whole-country policy. The US and Australia are, in contrast, federal states, where policymaking was adopted at the local level. In the US, the Federal government only assumed a leading role in 2021.
- The political environment: From the late 1990s, governments in England of all political persuasions generally welcomed e-cigarettes and saw them as key to anti-smoking policies. In the other two countries, little political support was given to e-cigarettes as part of harm reduction policies.
- The role of regulatory institutions: Regulatory institutions in England, primarily the Medicines & Healthcare Regulatory Agency and Public Health England, were heavily involved in the harm reduction agenda around smoking. Regulation at the regional level through the European Union was also important in cementing the focus on a consumer approach, which the European Parliament voted for, rather than a medicines regulation system of control. In the US, no unanimity of approach was found to exist at the Federal level: the Food and Drug Administration was more open to tobacco harm reduction than the Centers for Disease Control and Prevention. In Australia, regulation of nicotine went down the poisons route under the leadership of the Therapeutic Goods Administration.
- The pre history of nicotine regulation for cessation and harm reduction: England had an important pre-history of using nicotine as a therapy and substitute for smoking long before e-cigarettes came on the scene. In the US, the ‘brain disease’ model of addiction ensured that nicotine was seen as a threat to the developing adolescent brain. In Australia, leading tobacco control figures were sceptical about the need for nicotine replacement therapy.
- Professional networks in favour of or against e cigarettes: Professional networks, such as researchers working on nicotine since the 1970s and the tobacco group of the Royal College of Physicians, had a particular impact on policy in England. In the US by contrast, most professional networks were anti-e-cigarettes. The Australian network of tobacco control advocates and state cancer councils also supported the country’s sales ban for e-cigarettes.
- Activism and links with government: Outsider activist organisations in England, primarily Action on Smoking & Health, developed a ‘policy coalition’ of organisations with influence within government to support harm reduction well before e-cigarettes came on the scene. Neither Australia nor the US had set up a policy coalition, and activist organisations were almost entirely anti-nicotine and e-cigarettes.
- The impact of drugs, HIV and harm reduction: In England, harm reduction ideas from the drugs and HIV field were in a close institutional relationship through public health agencies. In the US, drug harm reduction has a more contested history, and in Australia policy influence was absent from the drug harm reduction field. Some drug harm reduction advocates even argued against e-cigarettes.
- Who policy is for: In England the initial key policy target was the chronic smoker. In the other two countries, the main concern was that children and young people would take up vaping. Policy has moved in this direction in England though the focus on the chronic smoker remains.
Recommendations
International and multidisciplinary knowledge exchange about the process involved in the introduction of e-cigarettes is important for policymaking because it raises awareness of key determinants of how policy is made, which policies are most likely to achieve the objectives sought, and how the process can be most effectively operationalised. From the evidence assembled in this study, the key factors that need to be considered by policymakers when they are reviewing policy evidence are:
- The importance of examining the pre history of how the issues both of harm reduction and nicotine use were dealt with prior to the arrival of e-cigarettes.
- Political support for the introduction of e-cigarette policies.
- The level of government where control over policymaking resides.
- Support from key stakeholders including professional networks and activist organisations.
- The readiness of the regulatory framework to accommodate the policy.
This briefing was written by Virginia Berridge FAcSS.