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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Am J Public Health. Author manuscript; available in PMC Nov 1, 2012.
Published in final edited form as:
PMCID: PMC3207640
NIHMSID: NIHMS330557
The Nature, Scope, and Development of the Global Tobacco Control Epistemic Community
Hadii M. Mamudu, PhD, MPA, MariaElena Gonzalez, PhD, and Stanton Glantz, PhD
Correspondence should be sent to Hadii M. Mamudu, PhD, MPA, Assistant Professor of Public Health, Department of Health Services Administration, College of Public Health, East Tennessee State University, PO Box 70264, Johnson City, TN 37614 (mamudu/at/mail.etsu.edu)
Reprints can be ordered at http://www.ajph.org by clicking the “Reprints/Eprints” link.
About the Authors: At the time of the study, Hadii M. Mamudu was with the Center for Tobacco Control Research and Education at the University of California, San Francisco. MariaElena Gonzalez and Stanton Glantz are with the Center for Tobacco Control Research and Education at the University of California, San Francisco.
Over the past 50 years, tobacco control has been transformed from a national to a global issue, becoming institutionalized in the World Health Organization (WHO) Framework Convention on Tobacco Control, the first international public health treaty negotiated under the auspices of the WHO. The global tobacco control epistemic community, a worldwide network of professionals with a common interpretation of the science in tobacco use and control, has contributed to this transformation. We investigated the development, structure, and function of this community through interviews and archival documents. Professionals in the community are bound by values and consensual knowledge developed after years of contentious debates undergirded their activities. Although these professionals play multiple roles, they recognize that scientific evidence should inform advocacy and policy activities. Public health professionals should continue to strengthen the links between science and advocacy for policy while being vigilant against industry efforts to undermine the scientific evidence on tobacco use and control.
Changed incrementally but dramatically between the early 1960s and 2010. The number of countries with tobacco control policies increased from 30 in 19761 to 91 in 19962 and to almost all in 2009.3 As of September 2011, there were 174 parties to the 2003 World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), the first international public health treaty negotiated under the WHO.4 The evolution of tobacco control from a national to international issue reflects the development and effectiveness of nonstate actors and the importance of the linkages between civil society and science.
Previous research on global tobacco control focused on advocacy networks,510 specific states,11,12 and governmental organizations.13 It is generally recognized that science influences policy in tobacco control.14,15 Although some authors have noted the integral role of an epistemic community in the broader tobacco control community and global tobacco control policymaking process,6,11,16,17 little is known about the epistemic community's characteristics. An epistemic community is a “network of professionals with recognized expertise and competence in a particular domain.”18(p3) It differs from social movements and advocacy networks by being characterized by consensual knowledge developed through scientific evidence, with the policy driven by science.1821 Epistemic communities often play important roles in influencing state policymaking behavior because they act as scientific gatekeepers in the policymaking process.
This community is important because of the crucial role nonstate actors play in global tobacco control policymaking8,11 and because tobacco companies view tobacco control advocates as having gained their policymaking influence through alliances with epistemic communities.22 Because of the scientific gatekeeping role that epistemic communities play in the policymaking process, it is important that public health professionals continue to strengthen the links between science and advocacy for policy and to be vigilant against industry efforts to undermine the scientific basis of tobacco control policies and of the global tobacco control epistemic community itself.
We triangulated 23,24 interviews and archival documents.
Interviews of Tobacco Control Professionals
We used 181 semistructured interviews of relevant professionals from 39 countries and 2 territories conducted between 1999 and 2006 (Table 1). Interviewees described how they became involved in tobacco control, expressed their knowledge of tobacco use and control, and narrated their activities to influence policy.
Table 1
Table 1
Characteristics of the Interviewed Professionals: The Nature, Scope, and Development of the Global Tobacco Control Epistemic Community, 1999–2006
Archival Documents
To understand who was involved in scientific consensus making, as well as the content and evolution of scientific consensual knowledge, we used published World Conferences on Tobacco or Health (WCTOH) proceedings (1967 through 2009), WHO tobacco control documents, and tobacco industry documents available at the Legacy Tobacco Documents Library (http://legacy.library.ucsf.edu) or Tobacco Documents Online (http://tobaccodocuments.org). We searched the industry documents between August 2006 and June 2009 using standard methods2527 beginning with “World conference on tobacco or health,” “anti-smoking movement,” “tobacco control community,” and “tobacco control movement.” We followed up searches using adjacent Bates numbers and named individuals and organizations. We retrieved more than 10 000 documents and used approximately 1000 for this analysis.
Analysis
We used grounded theory methodology28 to analyze the transcribed interviews without any weight to the responses or WCTOH abstracts. We performed open-ended, line-by-line text coding to identify conceptual labels and themes, which were merged into broader conceptual categories with Nvivo 8 (QSR International, Victoria, Australia) followed by descriptive statistics with PASW Statistics 18 (IBM, Chicago, IL).
As of 2010, the global tobacco control epistemic community was heavily networked and linked through nongovernmental organizations, Internet networks, and conferences. Although tobacco control professionals existed before 1967 when the WCTOH started, they were disparate actors located at the domestic level with little international interaction or collaboration. The First WCTOH provided the foundation for forming a global community, becoming a venue for training and idea exchange as well as setting the international policy agenda for individual tobacco control professionals and intergovernmental organizations, notably the WHO.11,13 In the 1970s and 1980s, WHO, its member states, and nongovernmental organizations involved in tobacco control deferred to tobacco control professionals for scientific information. This consolidated the epistemic community (see box on page e5) and enhanced its role as important actor in global policymaking in the 1990s.
Our data revealed tobacco control professionals' sense of belonging to a worldwide community. For example, Ron Borland, who in 2006 worked for the Anti-Cancer Council of Australia and was an International Tobacco Control Project collaborator, observed,
Well there is a community and the community is through things like the [WCTOH]. Because it's a relatively small group who are doing a lot of the research, we know a lot of the other people within that community, and if we don't personally know a person within the community, you can almost guarantee that somebody we know will know them…. And it's been held together by things like GLOBALink [an Internet network], which has been an incredibly important resource in providing a sense of global action and of sharing in global insights and resources. It has been relatively small. It's also been a thing that has helped build that sense of a community. You get out of one of these meetings and every second person you see, you know, which is fun. But, probably it's fair to say that up until the early 1990s, it was pretty much national rather that international (interview with Ron Borland, August 2006).
David Hill, a behavioral scientist and Director of the Cancer Council of Australia in 2006 also said,
It is my perspective that tobacco control has been a large informal club of committed enthusiasts, and we connect various ways. A really important vehicle for connecting has been the [International Union Against Cancer] from the very early days when Mike Daube [a longtime tobacco control professional who was the first Director of the UK-based Action on Smoking and Health from 1973 to 1979] and Nigel Grey [the head of the International Union Against Cancer in the 1970s and 1980s] and others ran a project or program hosted by the [International Union Against Cancer], and that connected up a lot of people and I was in a small way part of that from the 70s (interview with David Hill, August 2006).
Members of the global tobacco control epistemic community indicated that they shared a common goal and adversary (the tobacco industry) and a strong sense of solidarity fostered through the linkages described here. This phenomenon emerged partly as a result of the historical struggle for scientific supremacy between tobacco control professionals and the tobacco industry, which worked to undermine the emerging scientific consensus in the mainstream scientific community of the dangers of tobacco use and passive smoking.2933
Categories of Tobacco Control Professionals
There is overlap between research, advocacy, and policy development activities in the global tobacco control epistemic community.6,15 Interviewees distinguished between possessors of knowledge (experts, scientists, and researchers) and translators of knowledge to policies (advocates).14 Pekka Puska, the head of the Finnish Public Health Institute in 2007 (and active in tobacco control for 30 years) said,
clearly, there have been some different groups. Some people have clearly been scientists with their scientific background speaking out clearly…. And then there are people who also have more policy background (interview with Pekka Puska, January 2007).
Judy Wilkenfeld, Head of the International Program of the US-based advocacy organization, Campaign for Tobacco-Free Kids, also noted this distinction when she observed that since its creation, many experts and researchers in the Society for Research on Nicotine and Tobacco continued to resist efforts to involve them in the policymaking process (July 2006).
We identified four categories of tobacco control professionals within this community: scientists, researchers, or advocates; pure advocates (those primarily involved in translating scientific knowledge in tobacco use and control into policies and programs14); expert government officials; and pure scientists or researchers. As shown in Figure 1, which represents the knowledge-generating activities of the interviewees, although there are tobacco control professionals who focus on just research or just advocacy, most people play multiple roles. Articulating this point, Yusuf Saloojee of the National Council Against Smoking of South Africa, who has been working on tobacco-related issues for more than two decades said,
Figure 1
Figure 1
Categories of tobacco control professionals and the depth of knowledge-generation activities: The Nature, Scope, and Development of the Global Tobacco Control Epistemic Community, 1999–2006
I will see myself as both [an expert and an advocate]. I think you cannot be an advocate without having in-depth knowledge, and you need to be both an expert, someone who has in-depth knowledge, and then to be able to use that knowledge to advocate for policy. Perhaps I will see myself more—over the years—initially I was a researcher. So in that case I was purely much more of an expert. Now I am more interested in the practical utilization of knowledge. So I'm perhaps more of an advocate (March 2007).
The idea of transition between categories is especially common among expert government officials because people move in and out of governmental roles or retire from government but continue to be involved in generating tobacco control consensual knowledge.
Tobacco control professionals rely not only on their work but also on the work of others in the community for advocacy and policy development. For example, although pure advocates focus on advocacy and policy activities,14,34 they rely on consensual knowledge provided by others in the community for such activities. Sir Richard Peto, a UK epidemiologist involved in tobacco control for more than three decades, noted that scientists and researchers generate evidence, but
obviously, the actual taking of the [scientific] results and getting something done with them depends on lots of other people as well. If it was just me [a scientist] writing papers, then things wouldn't happen (October 2006).
Similarly, Margaretha Hugland of Sweden, president of the International Network of Women Against Tobacco, observed that the ties between expert government officials and researchers or scientists and advocates outside government help the government experts in the community to promote tobacco control against opposing governmental forces (January 2007).
Tobacco control professionals in the global epistemic community work to influence policy nationally and internationally from outside (99%) and inside (77%) governmental and intergovernmental institutions. Whereas local and national governmental institutions have provided venues for them to influence domestic tobacco control, since the 1970s the WHO provided the main venue for their influence of global tobacco control policymaking within the United Nations system, mostly through expert committees and advisory groups.35,36
Core Values and Beliefs
As shown in the box on page e5, five core values bound tobacco control professionals into a single global epistemic community at the time of this study (2005–2010). Ninety-three percent of the interviewees saw tobacco use and control as a public health issue and strongly believed that tobacco-induced morbidity and mortality were preventable. Simon Chapman, a professor in public health at the University of Sydney in Australia and editor of the journal Tobacco Control, said,
I think the main value that I see in evidence in a lot of speeches that people will either explicitly or implicitly be referring to– our values are about the right to live a decent lifespan free of preventable diseases. And tobacco, of course, is a huge cause of preventable disease, and morbidity, and early death. So, I think that's probably the thing that sits on top of tobacco control more than anything else (August 2006).
The issue of tobacco industry accountability for promoting tobacco use knowing that it is dangerous to health was addressed by 66% of the interviewees. Professor Chapman outlined the following rights of the public:
The right to redress, that is, if you have been harmed by a corporation, or a company, or a government activity, or something like that, you should be given some form of redress to right the wrongs that you've suffered.
The right to information to make an informed decision on the basis of full access to all the facts and relevant issues to making a decision as a consumer. And that is very relevant to issues like learning what's in tobacco, learning about compensatory behaviors when people smoke and the “lights and milds” deception, those sorts of issues (August 2006).
For Ruth Malone, a professor at the University of California, San Francisco, and tobacco industry documents researcher who succeeded Chapman as editor of Tobacco Control in 2009,
I think another [core value] is responsibility. I think one of the problems we have in [the US] is that everybody thinks it's all about individual responsibility and well, they knew smoking was bad and they still smoked. But the fact is that it's not responsible to keep promoting something that kills people. It's just not! That's not a responsible act. I think there is a value that's held within tobacco control that the industry should be held accountable for that lack of responsibility (September 2006).
Similarly, Kenneth Warner, Dean of the University of Michigan School of Public Health, observed, “one thing that unites the [tobacco control professionals] most is opposition to the tobacco industry and the desire to do something about tobacco use” (August 2006).
Emanating from the issue of industry accountability is social justice; something 65% of interviewees addressed. According to Michael Eriksen, who headed the US Centers for Disease Control and Prevention's Office for Smoking and Health in the 1990s and was Director of the Georgia State University Institute of Public Health, as well as a professor, at the time of the interview,
I think the core value comes down to social justice, that people are dying needlessly because they've been lied to by an organization, an economic organization that only cares about their own profitability. And that is a core value for tobacco control experts and advocates in general (October 2006).
The core value of commitment to scientific truth regarding tobacco use and control was identified by 55% of interviewees. This value emanated from concerns over the industry's longstanding strategy of misinforming people and undermining science through manufactured controversy about the health dangers of tobacco use and the effectiveness of tobacco control policies.33,37 Michael Cummings, a Senior Research Scientist at the Roswell College Park Cancer Center, observed, “Science has been a partner [of tobacco control professionals]. You cannot have credible advocacy without science” (September 2006). Similarly, Mary Assunta, a longtime advocate and doctoral student at the University of Sydney asserted, “While it's important to have passion, it's also important to utilize [scientific] evidence and to run with the evidence” (February 2008).
The issue of altruism or duty, which Pekka Puska referred to as “doing good, helping people, and the truth” (January 2007) was addressed by 46% of the interviewees. Ann McNeil, professor of health policy and promotion at the University of Nottingham in the UK and former chairperson of the WHO Scientific Advisory Committee on Tobacco Regulation, noted that
I worked on one committee, which was introducing a smoke-free policy into a psychiatric institution. I remember one of the key members of staff there said to me, “You know, if this work results in one person stopping smoking—one psychiatric patient stopping smoking, then it will all have been worthwhile.”… One individual's life is as important as looking at the broader public health goal (October 2006).
Consensual Knowledge
Consensual knowledge18,21,38 is important and necessary because it undergirds the activities of tobacco control professionals and their influence in policymaking (see box on page e5, Figure 2). The themes of papers presented at the WCTOH in particular reflected the global tobacco control epistemic community's shift from an early, medical view of tobacco control that focused on the individual smokers to the current, comprehensive public health view that includes advocacy and policy and program research (Figure 2). The shift in understandings of the tobacco problem emerged from epidemiological research,39 biomedical research,40,41 policy research,24,42 and archival documents analysis43 (see box on page e5). This knowledge has been accepted by decision-making elites in governmental organizations and became a catalyst for the FCTC.4446
Figure 2
Figure 2
Shift in the understanding of tobacco use and control in the global tobacco control epistemic community: Papers Presented at the World Conference on Tobacco or Health, 1967–2009
Health Effects of Tobacco Use
The dominant consensual knowledge that formed the basis for the global tobacco control epistemic community by 2005 to 2010 was negative health consequences of tobacco use and secondhand smoke, which first emerged in the 1950s and early 1960s,37,4749 particularly with the authoritative reports by the UK Royal College of Physicians50 and the US Surgeon General51 in 1962 and 1964 respectively. This consensus catalyzed the First WCTOH in 1967, during which US Surgeon General William Stewart said, “The proposition that cigarette smoking is hazardous to human health is no longer controversial.” 52(p9) This consensual knowledge expanded (Figure 2) to include the understanding that tobacco use occurred in a social context and environment in which the tobacco industry played an important role. This view served as the driving force for 93% of the interviewees who indicated that tobacco use and control is a public health issue.
Consensual knowledge of the dangers of secondhand smoke to nonsmokers15,53 emerged in the 1970s and 1980s amid contentious debates among tobacco control professionals and between them and the tobacco industry and its allies, who sought to controvert the evidence.30,54,55 Daube observed,
One of the other huge differences [between the 2000s and the 1970s] was that we didn't have scientific evidence for the [advocacy, education, and policy] campaign on passive smoking. Colossal difference! That has made so much difference. The passive smoking campaign has helped so many other aspects of the campaign. In [the 1970s], all we could say was that reducing passive smoking is helpful done with pressure. There was no evidence that we could take to the bank about the dangers of passive smoking other than anecdotal evidence, and a paper here or there.… there wasn't the evidence that started coming through from the days from Takeshi Hirayama and others [that linked secondhand smoke to health dangers]. So it's an enormous difference (July 2007).
By the early 2000s, the scientific evidence on the dangers of tobacco use and secondhand smoke had accumulated to the point that Douglas Bettcher, head of the WHO Tobacco Free Initiative, and others noted,
Scientific evidence has unequivocally established that tobacco use has devastating health consequences for users and for those exposed to tobacco smoke.44
Tobacco and Nicotine as Addictive
Addiction is an integral part of the health issues related to tobacco.32,5658 Until the 1980s, there was disagreement among tobacco control professionals (but not in the tobacco companies43,59) on whether tobacco use was a habit or addiction. The WHO Director General Halfdan Mahler demonstrated this uncertainty at the Sixth WCTOH in Japan in 1987 when he said,
Until fairly recently, smoking was considered not to be different from compulsive peanut or potato chip eating. That was an innocent view. Tobacco has been shown to be as addictive and as dependence-producing as hard drugs. It is psychoactive, affecting the chemistry of the brain and nervous system. Like hard drugs, tobacco is abused and misused.60(p11)
Since 1988, when the US Surgeon General identified nicotine as an addictive drug58 manufactured tobacco products have been recognized by tobacco control professionals as some of the most deadly dependence-producing substances available.61 In 2000, the Royal College of Physicians concluded that nicotine is a hard drug that is more addictive than heroin.57 As a result, tobacco control professionals widely believe that the tobacco industry's argument that tobacco use is an individual choice does not hold and these products should be regulated.45
The Economics of Tobacco Control
Consensual knowledge has emerged in the global tobacco control epistemic community that price measures curb tobacco use and that tobacco use creates a macroeconomic burden, including direct medical costs and lost productivity that exceeds any economic benefit of tobacco production and use. The evidence supporting this consensus emerged during the 1980s, grew in the 1990s,45,62,63 and culminated in the 1999 World Bank report Curbing the Epidemic,45 which concluded that tobacco control is good for health and the economy except few tobacco-dependent economies. Curbing the Epidemic provided economic justification for the FCTC and important policy tool for countering the tobacco industry's economic arguments.8,64 Prabhat Jha, a professor at University of Toronto in Canada who headed the World Bank team that prepared Curbing the Epidemic, said,
You know that the government is still, in developing countries, getting the arguments that were being raised 20 years ago in the US. Oh, that this is going to cost jobs or this is going to hurt the economy and so forth. So [Curbing the Epidemic] has helped in that way. At least it's a tool against the arguments of the tobacco industry (October 2006).
Comprehensive Approach to Tobacco Control
A consensus has developed that a composite of policies, programs, advocacy, and policy and program research (see box on page e5, Figures 1 and and2),2), moving beyond treating individual smokers (the original medical perspective), is necessary. From this perspective, because tobacco use encompasses human behavior and the social context within which such behavior is practiced,65,66 curbing the use and spread of tobacco demands different measures that reinforce each other. While ideas on tobacco control legislation (to prevent youth smoking) began in the 1980s, health warnings on cigarette packages and advertising bans began from the 1960s in developed countries.1,67,68 Codification of different national tobacco control measures at a global level began in the 1970s,35 when tobacco control professionals involved in the International Union Against Cancer published Lung Cancer Prevention: Guidelines for Smoking Control 69 in 1977 and Guidelines for Smoking Control70 in 1980. Before the Lung Cancer Prevention document was published, Daube noted,
There was no consensus policy. I think one of the most important steps that was taken was when Nigel Gray…. brought together that group in 1976. And it was a mix, as committees so often are, of experts within it. But he brought that group together under the auspices of the [International Union Against Cancer] to write the Lung Cancer Prevention: Guidelines for Smoking Control. And we wrote the first comprehensive tobacco control program…. Before then it had all been very naïve stuff, if you look at coverage in news in terms of their recommendations. And this was…. I think… a six-point comprehensive approach to tobacco control (July 2007).
Since the late 1970s, various tobacco control measures have been codified in nonbinding policy documents, including World Bank's Curbing the Epidemic45 and the Centers for Disease Control and Prevention's Best Practices,71 and negotiated binding policy documents, including the FCTC and its implementing protocols.4 This situation encouraged lesson drawing across institutional, political, and geographic jurisdictions.7274 Interviewees who had been in tobacco control for more than a decade agreed that countries seeking to design tobacco control policies should domesticate preexisting consensus evidence-based measures.
Tobacco Industry as “Vector” of Tobacco-Induced Diseases
The latest consensual knowledge in the global tobacco control epistemic community, that the tobacco industry is a disease “vector,” started to emerge in the late 1970s and early 1980s when the role of the tobacco industry in tobacco use and control started to become obvious (see box on page e5 and Figure 2).33
Although there was growing awareness since the late 1970s that the tobacco industry worked to undermine tobacco control,37,4749 the release of millions of tobacco industry documents in the mid-1990s and the resulting research75,76 made these facts obvious. Echoing the view of most experienced tobacco control professionals, Daube said, “the industry documents… [are] an absolute goldmine” because they revealed things that were suspected in the 1970s and the 1980s (July 2007). For Michael Cummings,
[Tobacco companies] have a lot of influence because they can share a lot of that money, but that is all it is. Why do they have influence? They have money. Do they have less influence today than they did [many years ago]? Yes. Why? Because their credibility [is too bad]! (September 2006).
In sum, at the time of our study, five areas of key consensual knowledge, which consolidated the global tobacco control epistemic community and guided the activities of tobacco control professionals, had emerged in the midst of contentious debates among tobacco control professionals and between tobacco control professionals and tobacco industry.
Beginning in the last half of the 20th century, tobacco control transformed from a national to a global issue and institutionalized by the FCTC. Previous scholars assumed the existence of a global tobacco control epistemic community18,20,21,77 without outlining its existence.6,11,16,17 This community originated with the First WCTOH in 196711 and by the 1990s had become a strong actor in the policymaking process. Although this community has transnational membership, it is bound together by core values (see box on page e5)78,79 that range from preventing tobacco-induced morbidity and mortality to altruism. Underlying this community is scientific information on tobacco use and control and consensual knowledge,18,20,21 such as the health dangers of tobacco use and secondhand smoke and the view that the tobacco industry is a disease “vector.” The underlying causal beliefs about the link between tobacco use and health, and the emphasis on science and best practices, distinguish this community from other groups or organizations in tobacco control, such as advocacy networks.5,6,8
The global tobacco control epistemic community includes four categories of professionals: scientists, researchers, and advocates; pure advocates; expert government officials; and pure scientists and researchers (Figure 1). Although tobacco control professionals in this community play multiple roles from knowledge generation to advocacy and policy development, there is a strong recognition of the difference between scientific activities and advocacy and policy activities. While these professionals work in different settings, they are connected through Internet networks, meetings and conferences.
Although several nonstate actors, such as social movements,80,81 advocacy networks,8,19,21 issue networks,20,82 and interest groups,83,84 are involved in national and transnational policy coordination,18,21 epistemic communities are distinguished by the emphasis on scientific interpretation and consensus.18,20,21,77 Since scholars first described epistemic communities in the 1970s,18,85 their key role in the public policymaking process has been identified at many levels of governance and issue domains,18,86 including the environment,77,87 international security,88,89 trade,90,91 and human rights,86 but not global tobacco control. Epistemic communities gain prominence when the issue(s) in their domain becomes institutionalized and allows them to shape states' interests,18,92 which is the case with the FCTC.
As noted earlier, central to any epistemic community is consensual knowledge, which usually takes many years to emerge and is refined as new evidence emerges,18,77 providing the evidence base for intergovernmental institutions, such as the FCTC.46 In fact, some scholars consider disagreements and contentious debates as symbolizing the existence of an epistemic community and vital for its existence.77 Consensual knowledge in global tobacco control emerged and evolved (Figure 2) amid debates among tobacco control professionals and between them and the tobacco industry. As in the development of all scientific knowledge, consensual knowledge in the tobacco control epistemic community began with disagreements and evolved to become a widespread body of knowledge, as exemplified by the evolution of the consensus on nicotine addiction32 and secondhand smoke as a cause of lung cancer.31 For example, at the time of this study in 2010, there was an ongoing debate among tobacco control professionals over the link between smoking and breast cancer in premenopausal women,9395 harm reduction versus eliminating all tobacco use,9698 and the proper balance between population-based and individual-based approaches to reducing tobacco use.99,100 While these debates illustrate how difficult it is for a scientific evidence to reach the status of consensual knowledge, they show the strength of the community. The shift from the medical view of tobacco use and control to a more public health view (Figure 2) suggests the community is dynamic.
Epistemic communities play a central role in the policymaking process18,21 by helping to define states' self-interest, elucidating the cause and effect relationship of a phenomenon, identifying solutions to existing problems, and identifying and finding solutions to new problems. Within the global tobacco control epistemic community, knowledge generation; advocacy, lobbying, and campaigns; and creative policy solutions and actions18,77 are seen as a single continuum, which is consistent with an earlier assumption about the community.6 Because of the in creasing complexity of global problems, states and policymakers usually defer to these experts for advice.18,101 Through a processes of learning,102,103 states sometimes adopt epistemic communities' policy preferences, which is the case in tobacco control where recommendations of WHO expert committees and advisory groups became background for the adoption of World Health Assembly resolutions on tobacco control.11 Although implementation of the FCTC at the country level has been slowed because of opposition from the tobacco industry,104109 the development of the FCTC and subsequent implementation guidelines is evidence of the influence of the tobacco control epistemic community. The global tobacco control epistemic community plays an influential role in tobacco control not only because it embodies scientific knowledge on tobacco use and control but also because governments and governmental organizations defer to it for information.
Implications for Public Health
Scientific evidence and consensual knowledge has been central to the global tobacco control epistemic community that helped institutionalize tobacco control in the FCTC. It behooves the general public health community to be aware that the strength of global tobacco control, as the tobacco industry correctly observed,22 lies in the alliance between epistemic communities and other actors in tobacco control. Engagement in advocacy and policy activities that are not driven by scientific evidence and consensual knowledge may weaken global tobacco control, especially in an issue domain with a wealthy adversary that has historically sought to undermine the scientific work of tobacco control professionals. At the same time, an epistemic community is dynamic and receptive to new evidence and ideas, which suggests that while the public health community should be vigilant against activities that undermine the link between science and policy, they should be involved in debates over new ideas. In the end, global health will benefit if scientists and researchers become involved in the translation of the generated knowledge into policy.
Limitations
We used the snowball method of data collection for the interviews, which generated a convenient sample, but which implies not all tobacco control professionals had equal chance of being selected for this study. Furthermore, the use of two different sets of interviews generated consistency concerns, but conformed to analysis of epistemic communities.18
Conclusions
Tobacco control transformed from a national to a global issue and became institutionalized as the FCTC, suggesting the importance of the awareness of all the actors that made this transformation possible. Central to this transformation was a range of scientific information provided by the global tobacco control epistemic community. The members of this community—tobacco control professionals—played multiple roles and were bound together by core values and their activities driven by consensual knowledge developed after years of contentious debates, something not previously documented in epistemic communities. Within this community, there is a strong recognition of the distinction between scientific or knowledge generation activities and advocacy and policy activities, and that the latter should be based on the former. Thus, while people in public health should be vigilant against activities, particularly by the tobacco industry, to undermine the scientific evidence on tobacco use and control, they should also realize that the global tobacco control epistemic community is dynamic. New scientific evidence and innovative ideas will continue to emerge, be contested, and either be jettisoned or become part of the consensual knowledge for tobacco control.
The Global Tobacco Control Epistemic Community
Core Values and Beliefs
  • Prevention of tobacco-induced morbidity and mortality
  • Industry accountability
  • Social justice
  • Commitment to scientific truth
  • Altruism or duty
Consensual Knowledge
  • Tobacco use and exposure to secondhand smoke are harmful to health
  • Tobacco is an addictive product and nicotine is a drug
  • Economics of tobacco control (tobacco control does not harm the economy and tobacco use imposes economic costs)
  • Comprehensive approach to tobacco control (policies, programs, advocacy, and policy and program research)
  • Tobacco industry as a “vector” of tobacco-induced morbidity and mortality that lacks credibility
Notions of Data Validation
  • Epidemiology
  • Biomedical research
  • Policy research
  • Archival research
Policy Enterprise (Evidence-Based or Best Practices)
  • Demand Side:
  • Smoke-free environments
  • Taxation
  • Health warnings
  • Advertising ban
  • Education
  • Treatments
  • Supply Side:
  • Ban on sale to and by minors
  • Illicit trade in tobacco products
  • Provide viable alternative sources of livelihood
Acknowledgments
This research was funded in part by a National Cancer Institute grant (CA-87472) and was supported by the College of Public Health at East Tennessee State University.
We thank Sallie George of the Robert Wood Johnson Foundation for giving us World Conference on Tobacco or Health proceedings.
Note. The funding agency played no role in the conduct of the research or preparation of the article.
Footnotes
Contributors: H. M. Mamudu originated the study, collected the data, and wrote the first draft of the article. M. Gonzalez helped with the writing of the article. S. Glantz supervised the project and participated in preparing all versions of the article.
Human Participant Protection: The institutional review boards of the University of California, San Francisco, and East Tennessee State University approved the interview protocol used in this study.
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