Implementation of the polluter pay's principle in tobacco control in the UK: a stakeholder analysis.

BACKGROUND: The polluter's pay principle (PPP) aims to internalise external costs and assign liability to the polluter for the harmful cost of their products to society. Tobacco companies continue to manufacture and sell harmful cigarettes, earning billions in profits each year from these products. Meanwhile, governments and their people are left to 'clean up' and deal with the detrimental health consequences. This paper explores with expert stakeholders how the PPP could be implemented within the context of tobacco control in the United Kingdom (UK). METHODS: Twenty-four semi-structured interviews and two follow-up discussion groups were conducted with UK and international experts on tobacco control, public health, economics, or law from the academic, public, private and third sector. Participants considered the facilitators and barriers to implementing the PPP to tobacco control in the UK. Thematic analysis was employed, aided by NVivo 12, and data were compared to examine the views expressed by the different types of experts. RESULTS: Stakeholders favoured the implementation of the PPP in the context of tobacco control and indicated that it could be acceptable and feasible to implement and that it would likely have support from policymakers and the public alike. Stakeholders unanimously agreed that any legislation and administration should be free from tobacco industry influence; however, differences arose concerning who should oversee the implementation. CONCLUSION: The PPP from environmental law was predominantly seen as an approach that could be usefully applied to the tobacco industry. However, there is no one size fits all template, therefore its implementation would need to be adapted to fit the UK context.

Expert views on high fat, salt and sugar food marketing policies to tackle obesity and improve dietary behaviours in the UK: a qualitative study.

BACKGROUND: There has been a lack of progress in reducing obesity in the United Kingdom (UK) despite Government strategies released over the last 30 years. These strategies, including the most recent publication from July 2020, have focused on childhood obesity and high fat, sugar and/or salt (HFSS) marketing restrictions, particularly broadcast advertising. In this study, we aimed to examine a range of expert views on the potential impact and the relative importance of such policies. METHODS: Semi-structured interviews were conducted with 42 experts in policy (n = 19), industry (n = 10), and advocacy (n = 13) with an interest in obesity. The UK Government's 2020 obesity strategy was used as a prompt to guide discussion on policy options. Qualitative thematic analysis was employed to answer the three research questions and themes were inductively coded within each research question. Data were also cross compared using matrix coding and a form of framework analysis to examine the views expressed by the different types of stakeholders. RESULTS: Reactions to the July 2020 proposal were mixed among policy and advocacy stakeholders, while commercial stakeholders expressed disappointment. A main theme emerging in all groups was frustration with the policy process and wishing to see more clarity regarding restrictions and their implementation. There was an overall lack of trust that the government would carry out their proposed plan and agreement that a more comprehensive, multi-sector approach aimed at the underlying drivers of obesity would be most effective, with some stakeholders indicating that some of the proposed policies could make a difference if implemented robustly. On the theme of promoting healthier options, some stakeholders suggested lowering the prices of 'healthy' products and making them more accessible to combat regressivity. There was a potentially surprising level of agreement between policy/advocacy stakeholders and commercial stakeholders, although commercial stakeholders were more likely to advocate for collaboration between government and industry as well as voluntary industry measures. CONCLUSION: While HFSS marketing restrictions have a role to play and send a strong signal - provided they are implemented comprehensively - investment in these policies needs to be part of wider efforts to tackle the underlying drivers of obesity.

User-generated content and influencer marketing involving e-cigarettes on social media: a scoping review and content analysis of YouTube and Instagram.

BACKGROUND: Evidence suggests that experimentation with e-cigarettes among young people is increasing. Social media is widely used by young people with user-generated content and influencer marketing particularly influential in promoting products. This paper documents a snapshot of online user-generated content and influencer marketing related to e-cigarettes on YouTube and Instagram. METHODS: Scoping review of relevant e-cigarette-related content on two social media platforms popular with youths, YouTube and Instagram, between June and August 2021. Content analysis was undertaken to examine text, audio, and video content, recording age restrictions, health warnings, page characteristics, and post characteristics. Narrative post content was coded using a coding frame that was developed inductively in response to emergent categories. RESULTS: Vaping was portrayed positively on social media; of the posts analysed, 86.5% (n = 90 of 104) of Instagram posts and 66.0% (n = 64 of 97) of YouTube videos. Warnings about age restrictions and health (e.g., nicotine addiction/toxicity) did not feature in the majority of posts; 43.3% (n = 42) of YouTube videos (n = 42) contained an age warning compared to 20.2% of Instagram posts (n = 21). While 25.8% (n = 25) of YouTube videos and 21.2% of Instagram (n = 22) posts contained a health warning. CONCLUSION: Of concern is the fact that the vast majority of YouTube and Instagram content about e-cigarettes promoted their use, and typically the content does not contain age and/or health warnings. These findings may highlight a priority for governmental policy to restrict the ability of marketers to reach youths with social media content promoting e-cigarettes.

Experts' views on how to design a tobacco control fund in the UK.

OBJECTIVE: To explore expert views on the potential value, and approaches to establishing and administering a tobacco control fund in the UK. DESIGN: Semistructured interviews and follow-up discussion groups. SUBJECTS: Twenty-four UK and international experts on tobacco control regulation, public health, economics or law from the academic, public, private and third sector. METHODS: Participants considered the relative merit of (1) general excise tax on retail tobacco sales; (2) ring-fenced hypothecation of excise taxes on retail tobacco sales; and (3) a direct levy on tobacco manufacturers. Preliminary synthesis of interview findings was deliberated on in two follow-up discussion groups to identify key considerations for policy design. RESULT: Most experts agreed that a ring-fenced tobacco control fund would be a valuable method of raising predictable and reliable funds from tobacco producers either using either companies' sales volume or market share as a way to establish the proportion they should pay. Experts predominantly recommended that a fund in the UK should be administered by a government body with devolved nation input and with an independent advisory group. They typically indicated that funding should be allocated yearly with a distribution at local, regional and national levels to support smoking prevention and cessation rather than treatment activities with priority given to measures that tackle smoking-related inequalities. CONCLUSION: There was overwhelming agreement by experts on the need to establish a tobacco control fund to help meet the proposed government tobacco-free targets to reduce adult smoking prevalence to 5% by 2030 (England) and 2034 (Scotland).

Understanding commercial actors' engagement in policy debates on proposed e-cigarette regulation in Scotland.

INTRODUCTION: There is growing concern about transnational tobacco corporations' (TTCs) and other commercial actors' involvement in e-cigarette policy development. Previous analyses suggest that TTCs used e-cigarette debates to demonstrate alignment with public health and re-gain policy influence. Less is known about the engagement of other types of commercial actors in e-cigarette policy debates. METHODS: This paper is the first to empirically analyse commercial actors' engagement in an e-cigarette policy consultation process and to examine their views on proposed regulation. It applies mixed methods, drawing on policy consultation submissions (n=32), semi-structured interviews (n=9) and a social network analysis of website links among 32 commercial actors. RESULTS: The results show that commercial actors' positions on e-cigarette regulation aligned with business interests. TTCs, independent e-cigarette manufacturers and other non-licensed commercial actors were opposed to most aspects of potential e-cigarette regulation (except for age of sale restrictions), whereas licensed commercial actors, including pharmaceutical companies, supported more stringent regulation. While collaboration was viewed as strategically important to gain policy influence, distinct commercial interests and concerns about TTC credibility led to strategic distancing and to collaboration being largely confined to sector boundaries. In addition to reiterating arguments employed by TTCs in previous regulatory debates, commercial actors focused on highlighting the technical complexity and harm reduction potential of e-cigarettes. CONCLUSION: Awareness of the various commercial interests and strategic positioning of commercial actors in e-cigarette policy should inform public health advocacy and policy development, including managing conflicts of interest in the context of Framework Convention on Tobacco Control Article 5.3.

Message framing to inform cancer prevention pricing interventions in the UK and USA: a factorial experiment, 2019.

OBJECTIVES: To advance understanding of how message framing can be used to maximise public support across different pricing policies for alcohol, tobacco and sugary drinks/foods that prevent consumption of cancer-causing products. DESIGN: We designed a 3×4×3 randomised factorial experiment to test responses to messages with three pricing policies, four message frames and three products. SETTING: Online survey panel (Qualtrics) in 2019. PARTICIPANTS: Adults (N=1850) from the UK and USA. INTERVENTIONS: Participants randomly viewed one of 36 separate messages that varied by pricing policy (increasing taxes, getting rid of price discounts, getting rid of low-cost products), four frames and product (alcohol, tobacco, sugary drinks/foods). PRIMARY AND SECONDARY OUTCOME MEASURES: We assessed the relationship between the message characteristics and four dependent variables. Three were related to policy support: (1) increasing taxes on the product mentioned in the message, (2) getting rid of price discounts and special offers on the product mentioned in the message and (3) getting rid of low-cost versions of the product mentioned in the message. One was related to reactance, a psychological response to having one's freedom limited. RESULTS: We found no effect for pricing policy in the message. Frames regarding children and reducing cancer risk moderated some outcomes, showing promise for real-world use. We found differences in support by product and reactance with greatest support and least reactance for tobacco policies, less support and more reactance for alcohol policies, and the least support and most reactance for sugary drinks/foods policies. CONCLUSIONS: Cancer prevention efforts using policy interventions can be informed by the message framing literature. Our results offer insights for cancer prevention advocacy efforts across the UK and USA and highlight that tax versus non-tax approaches to increasing the cost of cancer-causing products result in similar responses from consumers.

Policy congruence and advocacy strategies in the discourse networks of minimum unit pricing for alcohol and the soft drinks industry levy.

BACKGROUND AND AIM: Public health policy development is subject to a range of stakeholders presenting their arguments to influence opinion on the best options for policy action. This paper compares stakeholders' positions in the discourse networks of two pricing policy debates in the United Kingdom: minimum unit pricing for alcohol (MUP) and the soft drinks industry levy (SDIL). DESIGN: Discourse analysis was combined with network visualization to create representations of stakeholders' positions across the two policy debates as they were represented in 11 national UK newspapers. SETTING: United Kingdom. OBSERVATIONS: For the MUP debate 1924 statements by 152 people from 87 organizations were coded from 348 articles. For the SDIL debate 3883 statements by 214 people from 175 organizations were coded from 511 articles. MEASUREMENTS: Network analysis techniques were used to identify robust argumentative similarities and maximize the identification of network structures. Network measures of size, connectedness and cohesion were used to compare discourse networks. FINDINGS: The networks for both pricing debates involve a similar range of stakeholder types and form clusters representing policy discourse coalitions. The SDIL network is larger than the MUP network, particularly the proponents' cluster, with more than three times as many stakeholders. Both networks have tight clusters of manufacturers, think-tanks and commercial analysts in the opponents' coalition. Public health stakeholders appear in both networks, but no health charity or advocacy group is common to both. CONCLUSION: A comparison of the discourse in the UK press during the policy development processes for minimum unit pricing for alcohol and the soft drinks industry levy suggests greater cross-sector collaboration among policy opponents than proponents.

E-Cigarettes: A Disruptive Technology? An Analysis of Health Actors' Positions on E-Cigarette Regulation in Scotland.

Concerns have been raised that the divisions emerging within public health in response to electronic cigarettes are weakening tobacco control. This paper employed thematic and network analysis to assess 90 policy consultation submissions and 18 interviews with political actors to examine the extent of, and basis for, divisions between health-focused actors with regard to the harms and benefits of e-cigarettes and appropriate approaches to regulation in Scotland. The results demonstrated considerable engagement in e-cigarette policy development by health-focused actors and a widely held perception of strong disagreement. They show that actors agreed on substantive policy issues, such as age-of-sale restrictions and, in part, the regulation of advertising. Points of contestation were related to the harms and benefits of e-cigarettes and the regulation of vaping in public places. The topicality, limitations of the evidence base and underlying values may help explain the heightened sense of division. While suggesting that some opportunities for joint advocacy might have been missed, this analysis shows that debates on e-cigarette regulation cast a light upon differences in thinking about appropriate approaches to health policy development within the public health community. Constructive debates on these divisive issues among health-focused actors will be a crucial step toward advancing public health.

A discourse network analysis of UK newspaper coverage of the "sugar tax" debate before and after the announcement of the Soft Drinks Industry Levy.

BACKGROUND: On 6th April 2018, the UK Government introduced the Soft Drinks Industry Levy (SDIL) as a mechanism designed to address increasing prevalence of obesity and associated ill health by reducing sugar consumption. Given that the successful introduction of upstream food and nutrition policies is a highly political enterprise involving multiple interested parties, understanding the complex network of stakeholders seeking to influence such policy decisions is imperative. METHODS: Media content analysis was used to build a dataset of relevant newspaper articles, which were analysed to identify stakeholder agreement or disagreement with defined concept statements. We used discourse network analysis to produce visual representations of the network of stakeholders and coalitions evident in the debate as it was presented in UK newspapers, in the lead up to and following the announcement of the Soft Drinks Industry Levy in the UK, from May 2015 to November 2016. RESULTS: Coding identified 3883 statements made by 214 individuals from 176 organisations, relating to 47 concepts. Network visualisations revealed a complex network of stakeholders with clear sceptical and supportive coalitions. Industry stakeholders appeared less united in the network than anticipated, particularly before the SDIL announcement. Some key industry actors appeared in the supportive coalition, possibly due to the use of corporate social responsibility rhetoric. Jamie Oliver appeared as a dominant stakeholder, firmly embedded with public health advocates. CONCLUSION: This study highlights the complexity of the network of stakeholders involved in the public debate on food policies such as sugar tax and the SDIL. Polarisation of stakeholders arose from differences in ideology, focus on a specific policy and statements about the weight of evidence. Vocal celebrity policy entrepreneurs may be instrumental in gaining public and policy makers' support for future upstream regulation to promote population health, to facilitate alignment around a clear ideology.

Following in the footsteps of tobacco and alcohol? Stakeholder discourse in UK newspaper coverage of the Soft Drinks Industry Levy.

OBJECTIVE: In politically contested health debates, stakeholders on both sides present arguments and evidence to influence public opinion and the political agenda. The present study aimed to examine whether stakeholders in the Soft Drinks Industry Levy (SDIL) debate sought to establish or undermine the acceptability of this policy through the news media and how this compared with similar policy debates in relation to tobacco and alcohol industries. DESIGN: Quantitative and qualitative content analysis of newspaper articles discussing sugar-sweetened beverage (SSB) taxation published in eleven UK newspapers between 1 April 2015 and 30 November 2016, identified through the Nexis database. Direct stakeholder citations were entered in NVivo to allow inductive thematic analysis and comparison with an established typology of industry stakeholder arguments used by the alcohol and tobacco industries. SETTING: UK newspapers. PARTICIPANTS: Proponents and opponents of SSB tax/SDIL cited in UK newspapers. RESULTS: Four hundred and ninety-one newspaper articles cited stakeholders' (n 287) arguments in relation to SSB taxation (n 1761: 65 % supportive and 35 % opposing). Stakeholders' positions broadly reflected their vested interests. Inconsistencies arose from: changes in ideological position; insufficient clarity on the nature of the problem to be solved; policy priorities; and consistency with academic rigour. Both opposing and supportive themes were comparable with the alcohol and tobacco industry typology. CONCLUSIONS: Public health advocates were particularly prominent in the UK newspaper debate surrounding the SDIL. Advocates in future policy debates might benefit from seeking a similar level of prominence and avoiding inconsistencies by being clearer about the policy objective and mechanisms.

The palatability of sugar-sweetened beverage taxation: A content analysis of newspaper coverage of the UK sugar debate.

BACKGROUND: Excess sugar consumption, including sugar-sweetened beverages (SSBs), contributes to a variety of negative health outcomes, particularly for young people. The mass media play a powerful role in influencing public and policy-makers' perceptions of public health issues and their solutions. We analysed how sugar and SSB policy debates were presented in UK newspapers at a time of heightened awareness and following the announcement of the UK Government's soft drinks industry levy (SDIL), to inform future public health advocacy. METHODS & FINDINGS: We carried out quantitative content analysis of articles discussing the issues of sugar and SSB consumption published in 11 national newspapers from April 2015 to November 2016. 684 newspaper articles were analysed using a structured coding frame. Coverage peaked in line with evidence publication, campaigner activities and policy events. Articles predominantly supportive of SSB taxation (23.5%) outnumbered those that were predominantly oppositional (14.2%). However, oppositional articles outnumbered supportive ones in the month of the announcement of the SDIL. Sugar and SSB consumption were presented as health risks, particularly affecting young people, with the actions of industry often identified as the cause of the public health problem. Responsibility for addressing sugar overconsumption was primarily assigned to government intervention. CONCLUSION: Our results suggest that the policy landscape favouring fiscal solutions to curb sugar and SSB consumption has benefited from media coverage characterising the issue as an industry-driven problem. Media coverage may drive greater public acceptance of the SDIL and any future taxation of products containing sugar. However, future advocacy efforts should note the surge in opposition coinciding with the announcement of the SDIL, which echoes similar patterns of opposition observed in tobacco control debates.

'Language is the source of misunderstandings'--impact of terminology on public perceptions of health promotion messages.

BACKGROUND: The high level of premature death due to non-communicable diseases has been associated with unhealthful lifestyles, including poor diet. The effectiveness of public health strategies designed to promote health via messages focusing on food and diets depends largely on the perception of the messages by the public. The aim of this study was to explore public perceptions of language commonly used to communicate concepts linking health, food and the diet. METHODS: This study is a qualitative and semi-quantitative cross-sectional survey exploring public perceptions of terms used to improve eating habits within public health strategies. We recruited adults with no background in nutrition or health-care, from May to July 2013, from urban areas of varying deprivation (n = 12) in Glasgow and Edinburgh, UK. Four key prompt-terms used to convey the idea of improving health through diet were selected for testing: Healthy Eating, Eating for Health, Balanced Diet and Nutritional Balance. Consumer understanding of these terms was explored using mixed-methods, including qualitative focus groups (n = 17) and an interviewer-led word-association exercise (n = 270). RESULTS: The word-association exercise produced 1,386 individual responses from the four prompt-terms, with 130 unique responses associated with a single term. Cluster analysis revealed 16 key themes, with responses affected by prompt-term used, age, gender and socio-economic status. Healthy Eating was associated with foods considered 'healthy' (p <0.05); Eating for Health and Balanced Diet with negative connotations of foods to avoid (both p <0.001) and Nutritional Balance with the benefits of eating healthily (p <0.01). Focus groups revealed clear differences in perceptions: Eating for Health = positive action one takes to manage existing medical conditions, Healthy Eating = passive aspirational term associated with weight management, Balanced Diet = old fashioned, also dieting for weight loss, Nutritional Balance = maximising physical performance. Food suppliers use Healthy Eating terminology to promote weight management products. Focus group participants welcomed product reformulation to enhance food health properties as a strategy to overcome desensitisation to health-messages. CONCLUSIONS: Public perceptions of messages communicating concepts linking health, food and the diet are influenced by terminology, resulting in confusion. To increase individual commitment to change eating habits in the long term, public health campaigns need strengthening, potentially by investing in tailored approaches to meet the needs of defined groups of consumers.