Barriers to evidence-based tobacco control in Tasmania Kathryn Iona Barnsley B.A. Grad. Dip. (Soc. Sci.) Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy, School of Medicine, University of Tasmania March 2016 Barriers to evidence-based tobacco control in Tasmania Supervisor: Clinical Professor Richard Wood-Baker, Breathe Well: Centre of Research Excellence for Chronic Respiratory Disease and Lung Ageing, School of Medicine, University of Tasmania, Hobart Co-supervisor: Professor Haydn Walters, Breathe Well: Centre of Research Excellence for Chronic Respiratory Disease and Lung Ageing, School of Medicine, University of Tasmania, Hobart. This thesis contains no material which has been accepted for a degree or diploma by the University or any other institution, except by way of background information and duly acknowledged in the thesis, and to the best of my knowledge and belief no material previously published or written by another person except where due acknowledgement is made in the text of the thesis, nor does the thesis contain any material that infringes copyright. This thesis may be made available for loan and limited copying and communication in accordance with the Copyright Act 1968. The publishers of the papers comprising Chapters 5, 6, and 7 hold the copyright for that content, and access to the material should be sought from the respective journals. The remaining non published content of the thesis may be made available for loan and limited copying and communication in accordance with the Copyright Act 1968. Kathryn Barnsley: doctoral thesis Page i Barriers to evidence-based tobacco control in Tasmania Statement of Co-Authorship The following people and institutions contributed to the publication of work undertaken as part of this thesis: Kathryn Iona Barnsley, (Candidate) Richard Wood-Baker, School of Medicine Eugene Haydn Walters, School of Medicine Author details and their roles: Paper 1 Crony Capitalism or Corruption? The Curious Case of British Tobacco and a Tasmanian Government. Located in Chapter 5. Kathryn Barnsley, Candidate was the sole author on this paper. Paper 2, Bureaucratic Barriers to Evidence-based Tobacco Control Policy: A Tasmanian Case Study. Located in Chapter 7. Kathryn Iona Barnsley, (Candidate) Richard Wood-Baker, School of Medicine Eugene Haydn Walters, School of Medicine Candidate was the primary author and author 2 and 3 assisted with refinement and presentation. Paper 3 A third paper has been accepted Evidence and Policy Journal. Scheduled for publication in May 2016. Political barriers to evidence-based tobacco control policy: cronyism and cognitive dissonance, a Tasmanian case study. Located in Chapter 6. Kathryn Iona Barnsley, (Candidate) Richard Wood-Baker, School of Medicine Eugene Haydn Walters, School of Medicine Candidate was the primary author and author 2 and 3 assisted with refinement and presentation. We the undersigned agree with the above stated “proportion of work undertaken” for each of the above published (or submitted) peer-reviewed manuscripts contributing to this thesis: Signed: ___ ___________ ____________________ Clinical Prof. Richard Wood-Baker Prof. Ben Canny Supervisor Head of School School of Medicine School of Medicine University of Tasmania University of Tasmania Date:____6 March 2016_________________ Kathryn Barnsley: doctoral thesis Page ii Barriers to evidence-based tobacco control in Tasmania Acknowledgements I express considerable gratitude to my primary supervisor Clinical Professor Richard Wood-Baker for his guidance, and most particularly for his persistence and patience in continuing to support this study, over many years. Prof. Wood-Baker has been an inspirational and gifted supervisor. Professor Haydn Walters has given great encouragement, support and advice to me for the last few years. Staff and fellow students at Breathe Well: Centre of Research Excellence for Chronic Respiratory Disease and Lung Ageing, in particular Dr Julia Walters and Steve Weston have been particularly supportive, and helpful during times of various life crises. Dr Erica Bell was most helpful in providing advice on writing styles, and I was sad that she unexpectedly died before she could see the completion of this thesis. For the historic chapter and article on crony capitalism regarding events in the 1960s and 1970s I acknowledge the assistance of Sir Max Bingham, Associate Professor Roslynn Haynes, staff of the Tasmaniana Library and Archives office of Tasmania, Tasmanian Parliamentary Library, University of Tasmania Library and staff at the Department of Primary Industries, Parks, Water and Environment. I also acknowledge and thank the hard-working and dedicated staff of the Department of Health and Human Services for their help over the years. Dr Melanie Wakefield, Cancer Council Victoria, encouraged the idea of this project many years ago, as there has been so little written or studied in depth regarding the political, bureaucratic and policy processes in Australia in relation to tobacco control. My friends Dr Maryjean Hope-Wilson and Shirley Abel always provided helpful advice and boosted my confidence to continue when times were tough. Dr. Sharon Moore, Jennifer Bradley were also of great assistance. Finally, I would like to thank my friends and family, who provided me with great comfort and emotional support throughout the process. In particular, my husband Simon Barnsley and daughters Hannah Smith and Morgan Barnsley. My mother Amy Matthews, who died in 2014, supported my education for my entire lifetime, and was always my most loyal, indefatigable and enthusiastic supporter to the end of her days. Kathryn Barnsley: doctoral thesis Page iii Barriers to evidence-based tobacco control in Tasmania This thesis is dedicated to tobacco-control policy advocates everywhere, who bravely stand up and speak, study, research, write and agitate against the forces of darkness – the diabolical death-dealing international tobacco industry. Kathryn Barnsley: doctoral thesis Page iv Barriers to evidence-based tobacco control in Tasmania Abstract Tobacco-smoking is by far the biggest single killer of Tasmanians, exceeding all motor vehicle accidents, illicit drugs, alcohol, suicide, homicide, fires and assaults combined. The tobacco industry is the vector of multiple chronic and deadly diseases caused by smoking, which can affect every organ of the body. Tasmania has higher smoking rates than all other states in Australia, and for a decade in the 2000s, the smoking rate in Tasmania did not fall at the same speed as other states. Tobacco control in Tasmania has been characterised by a strong legislative reform agenda, but weak commitment to allocation of resources for mass-media campaigns and cessation-support services. This thesis was triggered by professional concerns about these issues, and examines barriers to the funding of evidence-based tobacco control in Tasmania. The hypothesis is that there are specific barriers to implementing evidence-based tobacco-control measures in Tasmania. The initial proposal and research questions related to: evidence transfer to politicians and bureaucrats, and how such evidence is used and influenced; the role of policy entrepreneurs; factors influencing resource allocation; and does it matter if a politician is a smoker? The theoretical framework used was that of Kingdon, and agenda setting. The work began with a literature search focusing on evidence and knowledge transfer, and then progressed to requests for documents from the Department of Health and Human Services (DHHS) and other relevant agencies. In the early stages there was considerable cooperation from the DHHS, including access to files. In the later stages, with follow-up as the documents were read and analysed and more questions arose, DHHS and other departments insisted on formal requests in conformity with the relevant right to information legislation. A 1970s case of corruption and cronyism involving the tobacco industry was discovered at an early stage, and recently released archived files were examined to give a historic context to recent issues. Initially it had been intended to conduct interviews with bureaucrats, politicians and non-government leaders. However, as the researcher and all supervisors were embedded in the Tasmanian health community, it became clear that the small-scale nature of Tasmania meant that the answers given would almost certainly be confounded by Kathryn Barnsley: doctoral thesis Page 1 Barriers to evidence-based tobacco control in Tasmania familiarity. Further, a vast amount of information was available in documents. Therefore, it was decided to examine what people said and did as documented contemporaneously. The first major finding was that crony capitalism involving the tobacco industry was deeply embedded in the Tasmanian political system, and had been for decades. In the 1970s a tobacco company had managed, through corrupt processes, to eject an unsupportive Tasmanian government from office. No noteworthy ideological differences between the major political parties on tobacco control were found, as their actions appeared to be personality-driven. “Conservative white males” dominated governments, and it was not until 2013 that a bloc of progressive female political leaders finally broke the impasse, and allocated adequate funding to tobacco control. Senior politicians were poorly informed about the importance of tobacco control, and the evidence on how to reduce smoking rates. Many of the significant politicians