Stakeholder engagement in European health policy : a network analysis of the development of the European Council Recommendation on smoke-free environments
Background: With almost 80,000 Europeans estimated to die annually from the
consequences of exposure to second-hand smoke (SHS) and over a quarter of all Europeans
being exposed to the toxins of cigarette smoke at work on a daily basis, SHS is a major
European public health problem. Smoke-free policies, i.e. policies which ban smoking in
public places and workplaces, are an effective way to reduce exposure. Policy options to
reduce public exposure to SHS were negotiated by European Union (EU) decision makers
between 2006 and 2009, resulting in the European Council Recommendation on smoke-free
environments. A variety of stakeholders communicated their interests prior to the adoption
of the policy. This thesis aims to analyse the engagement and collaboration of organisational
stakeholders in the development of the Council Recommendation on smoke-free
environments.
Methods: The case study employs a mixed method approach to analyse data from policy
documents, consultation submissions and qualitative interviews. Data from 176 consultation
submissions serve as a basis to analyse the structure of the policy network using quantitative
network analysis. In addition, data from these submissions, selected documents of relevance
to the policy process and 35 in-depth interviews with European decision makers and
stakeholders are thematically analysed to explore the content of the network and the
engagement of and interaction between political actors.
Results: The analysis identified a sharply polarised network which was largely divided into
two adversarial advocacy coalitions. The two coalitions took clearly opposing positions on
the policy initiative, with one coalition supporting and the other opposing comprehensive
European smoke-free policy. The Supporters’ Alliance, although consisting of diverse
stakeholders, including public health advocacy organisations, professional organisations,
scientific institutions and pharmaceutical companies, was largely united by its members’
desire to protect Europeans from the harms caused by SHS and campaign for
comprehensive European tobacco control policy. Seemingly coordinated and guided by an
informal group of key individuals, alliance members made strategic decisions to collaborate
and build a strong, cohesive force against the tobacco industry. The Opponents’ Alliance
consisted almost exclusively of tobacco manufacturers’ organisations which employed a
strategy of damage limitation and other tactics, including challenging the scientific evidence,
critiquing the policy process and advancing discussions on harm reduction, to counter the
development of effective tobacco control measures. The data show that the extent of tobacco
company engagement was narrowed by the limited importance that industry
representatives attached to opposing non-binding EU policy and by the companies’ struggle
to overcome low credibility and isolation.
Discussion: This study is the first that applies social network analysis to the investigation of
EU public health policy and systematically analyses and graphically depicts a policy
network in European tobacco control. The analysis corroborates literature which highlights
the polarised nature of tobacco control policy and draws attention to the complex processes
of information exchange, consensus-seeking and decision making which are integral to the
development of European public health policy. The study identifies the European Union’s
limited competence as a key factor shaping stakeholder engagement at the European level
and presents the Council Recommendation on smoke-free environments as an example of
the European Commission’s successful management of the policy process. An increased
understanding of the policy network and the factors influencing the successful development
of comprehensive European smoke-free policy can help to guide policymaking and public
health advocacy in current European tobacco control debates and other areas of public
health