Comprehensive Tobacco Control Policy Regimes and Population Health: Assessing Causal Loops

Tobacco products remain among the most controversial consumer products of all time: cigarettes are the only legal product that, when used as intended, are lethal. The global and individual burden attributable to the primary use of tobacco, or secondary or tertiary exposure to cigarette smoke, whether measured by morbidity, mortality, or economic costs, is substantial. With the combined efforts of scientific research, public health and policy advocates, the image and use of tobacco products has undergone profound change. However, while much has been achieved regarding the attitudinal, behavioral, and policy changes needed to diminish the individual, social, and economic costs of tobacco use, much remains to be yet accomplished if these adverse tobacco use impacts are to be further curtailed. There is considerable evidence that tobacco use is becoming highly concentrated in lower socio-economic groups and that the rate of decline in smoking is slowing. Further, as the tobacco epidemic emerges in the developing world, there is considerable interest line applying the lessons learned in industrialized countries to developing countries, thereby truncating the tobacco epidemic and forgoing some of the enormous costs in countries least able to absorb such costs.;The unifying theme of the present work is an integration of the public health and political science perspectives on tobacco control so as to establish a more comprehensive framework of the underlying factors and elements interrelating tobacco use and tobacco control policy. A substantial challenge in developing such a framework is the complexity of the relationship between the two primary outcomes of interest. The relationships, including interdependencies and feedback mechanisms, are much more accurately characterized by a causal loop. This work presents an overview of the tobacco epidemic, a review of two very different literatures with different perspectives on the tobacco epidemic (public health literature and political and policy science), an empirical policy history analysis integrating the political and policy science viewpoint with the public health perspective on the evolution of the tobacco epidemic, and two quantitative analyses alternately supporting the interdependence and complex temporal relationship between tobacco control policy adoption and population health outcomes as well as the importance of societally-derived factors. An integrated conceptual model based on the causal loops of tobacco control policy and tobacco-related population health is then presented that incorporates the realms of population, governmental, judicial, public health, tobacco industry and other subsystems, and scientific communities. However, while this framework does assimilate the key elements and forces elucidated during the course of this work and integrates the political and policy science with the public health perspective, in truth this framework likely elicits more questions than it answers. The research questions and agendas and metrics proposed highlight both the strengths and deficiencies of the two perspectives