Background
Tobacco control is one of the public health priorities, and the tobacco epidemic is one of the greatest public health threats the world has ever faced. Further, smoking is the leading cause of preventable death in the world [
1,
2]. Globally, tobacco accounted for 8.71 million deaths and was the second-leading risk factor for deaths and the third-leading risk factor for disability-adjusted life years (DALYs) in 2019. In Iran, tobacco was the fourth-leading risk factor for attributable DALYs after high blood pressure, high body-mass index, and high fasting plasma glucose in 2019 [
3]. The economic costs of smoking are significant, causing hundreds of billions of dollars in economic losses each year worldwide. According to the World Health Organization (WHO), two to three times the cost of smoking is used to treat diseases caused by tobacco use. Besides the high public health costs of treating tobacco-related diseases, smokers are less productive due to the increased incidence of the disease and those who die prematurely deprive their families of much-needed income. Tobacco use and poverty are inextricably linked. Tobacco use increases poverty and prevents economic development [
4].
Studies showed that tobacco consumption is increasing in Iran, especially among women, and the age of onset is decreasing. The first global and international tobacco control efforts date back to 1987. Since 1998, the Tobacco Control Program has been at the forefront of the WHO to reduce the global burden of deaths and diseases related to tobacco. A working group was formed to formulate the Tobacco Control Framework Treaty, which in 2003 led to the ratification of the framework convention on tobacco control (FCTC) [
5]. Iran also joined the FCTC in 2005. Achieving the effectiveness of policies requires policy changes that arise from the agenda-setting stage, and the purpose of this study was to review and analyze these cases. On the other hand, this study aimed to identify three streams and examine how policymakers placed tobacco control as a political priority in the agenda-setting in Iran over a 30-year timeframe.
Conceptual framework
We applied Kingdon’s multiple-streams framework (MSF), one of the most commonly used agenda-setting models, as a framework for analysis [
6]. Agenda-setting is the first stage of the policy-making process. According to MSF, when the three problem streams, policy streams, and political streams exist, policymakers consider the issue, and it moves onto the agenda [
7,
8]. The Problem Streams involve convincing policymakers to pay special attention to one issue due to various statistical indicators, political reports, and pressure from advocacy groups. The Policy Stream involves many ideas competing for acceptance, and a policy solution emerges to solve the problem in this condition. The chances of accepting ideas will increase technical feasibility, acceptance of values, and are in line with the prevailing ideological streams. Political Stream indicated macro-level political situations affected by national mood, changing public opinion, pressure group campaigns and managerial/legal changes [
9‐
12].
This framework assumes that when these three streams come together at critical time points, a “window of opportunity” will appear. When a window opens, policy entrepreneurs should seize the opportunity immediately, take steps to link problems to solutions and perform advocacy of politicians who are receptive to their ideas [
10,
13].
Methods
We conducted this retrospective policy analysis using a case study approach based on Kingdon’s agenda-setting framework to examine Iran’s tobacco control policy process over the past three decades (1984–2016). We applied MSF to analyze principle factors influencing the problem stream of tobacco use, the solutions to control tobacco use, and the political events that affect tobacco control policies. We collected qualitative data using semi-structured interviews with key informants (n = 36) and reviewing archival policy documents (n > 100).
Document review
We analyzed all available policy documents related to tobacco. These documents mainly included policy documents, laws, regulations and government reports, scientific literature, national studies and newspaper articles and minutes of meetings. Then, we identified the available governmental reports by searching the web pages of the Iranian government agencies, the Ministry of Health and Medical Education (MoHME), the Universities of Medical Sciences, and related research centers.
We conducted semi-structured interviews for key informants and stakeholders by PhD students in health policy at the time of the study. We developed the interview guide based on a conceptual framework and literature search and piloted it before the study began. The research team confirmed its validity. We applied purposive and snowballing sampling to address key informants. The sequence of questions was not the same for all participants and varied depending on the participants’ research stages and answers. We interviewed 33 key informants and continued until the saturation of data. The majority of interviewees were men (
n = 24). We interviewed some stakeholders for over one session. We conducted 36 interviews with 33 stakeholders, seven of whom were from different levels of the MoHME, 6 participants were academics and researchers, and 5 were anti-tobacco related non-governmental organizations (NGOs). The other 15 participants were from the Ministry of Interior, Ministry of Economic Affairs and Finance, Ministry of Education, Ministry of Culture and Islamic Guidance, Ministry of Industry, Mine and Trade, headquarters for combating the smuggling of commodities and foreign exchange, Parliament, Municipality of Tehran, Islamic Republic of Iran Broadcasting (IRIB). These interviews took place between 2016 and 2018. Before starting interviews, the researcher performed communication techniques, explaining the research process and ensuring that information would be kept confidential. Then, we started the interviews with an open question and tried to guide the interview process to cover the research objectives by using interview techniques. The interviews lasted between 35 and 65 min, which was an average of 50 min. During the interview, we refused any orientation to the participants’ opinions to ensure that only the participant’s opinion was collected. We performed all interviews face-to-face and recorded them with informed consent. Besides, we asked the following questions about the problem stream and policy stream politics stream:
How, when and by whom did the issue of tobacco enter the government’s agenda?
What were the solutions suggested by different organizations to address tobacco-related issues in Iran?
What were the political factors that have influenced tobacco policies in Iran? What has been the impact and political communication with stakeholders in the policy-making process?
Data analysis
We used the framework analysis to analyze the data based on applying MSF. In the first step, we read the archival documents and transcribed interviews repeatedly to familiarise researchers with data. Then, we categorized data through coding and summarization techniques. Two authors performed open-ending coding to extract themes. Two researchers discussed disagreements to resolve. According to Kingdon’s framework, we extracted themes, including problem identification, policy solutions, and political opportunities. We used MAXQDA 11 software to analyze the data. We conducted the study and reported by consolidated criteria for reporting qualitative research (COREQ) guidelines [
14].
Ethical issues
The Research Ethics Committee of the Tehran University of Medical Sciences (TUMS) approved the study (code 8921557003). We provided the interviewees with an oral explanation of the nature and objectives of the research. All interviewees received information about the research and the consent form before the interview and had the right to withdraw from the study at any stage of the research. We observed the principle of confidentiality of information in the research results and did not state the issues that led to the recognition of the interviewee. We provided the results of the research to the interviewees upon their request.
Discussion
The tobacco control agenda-setting process in Iran was broadly consistent with Kingdon’s multiple-streams framework. As the findings showed, this process results from changes in three streams and the existence of political actors to link these streams and tap the opportunity window. These findings are consistent with studies conducted in different countries relevant to tobacco control [
34‐
36]. In the present study, several factors facilitated the connection of streams and opened the opportunity window. Moreover, several factors facilitated the connection of flows and the opening of the opportunity window, including indicators on the severity of the problem, shaping the issue, feedback from past policies, the existence of a comprehensive proposal or national control of tobacco, the requirement of the Expediency Council to the government and the FCTC. In this study, the political stream of the FCTC had the most significant impact on the agenda-setting process. Various studies have also emphasized the importance of ratifying the FCTC as the first global evidence-based treaty on public health in different countries in creating an opportunity window and agenda-setting process [
35,
37,
38]. In a study conducted in Turkey, tobacco control had become a political priority because of the development and convergence of multiple streams, including a fourth, a separate global stream. This global stream included the FCTC, the Bloomberg Initiative for tobacco control, and the global tobacco control network. In the Turkish study, we observed the importance of foreign policy in the evolution of the political stream. The country’s desire to join the European Union led to creating a political environment that embraced global norms for tobacco control and helped open the window of opportunity [
35].
In our study, the role of policy entrepreneurs in linking streams and using the policy window was crucial. These policy entrepreneurs were in tobacco-related NGOs, members of the National Tobacco Control Headquarters at the MoHME, and the Islamic Consultative Assembly members. Other studies have pointed to the leadership of key informants and their role in advocacy and leadership change [
14,
34‐
36,
39‐
42]. The motivations behind the actions of these individuals and key leaders go back to their interests, experiences, expertise, values, beliefs, and political ideologies in the studies included [
14,
34,
36,
40,
42]. In Turkey, for example, high-ranking politicians, including former Prime Minister and current President, Recep Tayyip Erdogan, Dr. Recep Adag, former Minister of Health, and Dr. Erdol, Chairman of the Parliamentary Health Commission, also Erdogan’s physician, were all non-smokers interested in tobacco control.
The present study results showed that contrary to Kingdon’s theory that the three-stream streams are independent of each other [
6], these three-streams had influenced each other. Thus, the political stream (FCTC) had strengthened the political stream (Comprehensive Plan for the Control and Control of Tobacco), and on the other hand, the strengthening of the policy stream cause further strengthened the political stream [
35,
43].
The policy context has had a significant impact on the policy process of tobacco control in Iran. The influence of religious factors was an influence on tobacco control policy [
20].
The most important international factors in the country influencing tobacco control policy were: access to the FCTC, protocol on the elimination of illicit trade in tobacco products, united nations policy declaration on the prevention and control of noncommunicable diseases 2011, sustainable development goals 2030, international organizations, international sanctions against Iran, international exploitation, international foreign media, modernization and globalization, and tobacco control experiences from other countries. These factors influenced both the agenda-setting and the policy solution [
35]. Global agenda-setting influenced the agenda-setting in different countries. The role of contributions from international organizations, such as the WHO, has been mentioned in some studies. Their role in the studies included the publication of problem reports [
35], technical assistance [
35,
38], and financial assistance to tobacco control activities [
35]. They have also been influential in the policy-making process in several studies by transnational tobacco companies [
35,
38]. In several studies, the requirements related to before and after joining the unions and global treaties were influential in the agenda-setting [
35,
38,
39,
44]. For example, Turkey’s strong desire to join the European Union created a political environment. Turkey has adopted global tobacco control norms to comply with the standards and norms of the European Union, Turkey has adopted global tobacco control norms [
35]. Various studies have emphasized the importance of ratifying the WHO FCTC as the first evidence-based global public health treaty in various countries to create a window of opportunity for policy development [
35,
37,
38].
Limitations of study
The present study has some limitations. The first limitation was the problem of recalling information about processes and events related to past policy-making and legislative processes because of the long analysis period of some interviewees. In these cases, we tried to resolve this issue by using documents and reviewing the findings with several experts in this field. The second limitation was the issue’s sensitivity, which prevented stakeholders from engaging effectively and seriously in interviews. The researcher tried to increase the participants’ trust in the importance and application of research, the confidentiality of the information and the non-recording of audio to solve these problems. The following limitation refers to Kingdon’s framework, which originated in developed countries and has not been adapted to developing countries’ social and political context. As for the Kingdon’s framework, the results showed it needs to be adjusted and contextualized. The next constraint is related to exploring the unclear effect of entrepreneurs on the opening of policy windows and the ambiguity between them. Therefore, researchers use MSF to identify agenda-setting, especially in the health sector, and reduce potential limitations by combining it with other theories and models.
Conclusion
The tobacco control agenda-setting process in Iran was broadly consistent with MSF. The present study results showed that contrary to Kingdon’s theory that the three-stream are independent, this three-stream had influenced each other. Thus, FCTC as a policy stream had strengthened the comprehensive plan for controlling tobacco as a political stream. On the other hand, the strengthening of the policy stream caused to strengthen the political stream further. However, there were several challenges in developing effective policies for tobacco control in the Iranian context.
In the problem stream, tobacco control actors need to ensure that credible indicators are available, providing evidence of the severity of the problem to policymakers, decision-makers, and the public. Also, the problem of tobacco should be raised as an issue that needs immediate attention and action. Regarding the policy stream, tobacco control advocates must form a solid coalition to reach a collective agreement on solving the problem. Therefore, evidence-based recommendations from global organizations such as the WHO can facilitate accepting solutions among stakeholders. In the political stream, although actors may not be able to directly influence the change of government or their different commitment to tobacco control or change of national mood, they must learn to recognize when the political environment is ready for change and prepare themselves to influence influential people in this field. Integrating health diplomacy into tobacco control in the country’s foreign policy as a political stream can also strengthen international cooperation and join groups working on the issue in other countries. It will improve the use of international experiences in the country. In terms of joining the three streams, the actors must prepare themselves for the policy window to open to include their favourite issues on the agenda. Therefore, we recommend paying attention to the process of policy change based on streams and making evidence-based decisions.
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