Comment
6
7
8
Bhatia S. Long-term health impacts of hematopoietic stem cell transplantation inform recommendations for follow-up. Expert Rev Hematol 2011; 4: 437–52. Güngör T, Teira P, Slatter M, et al, on behalf of the Inborn Errors Working Party of the European Society for Blood and Marrow Transplantation. Reduced-intensity conditioning and HLA-matched haemopoietic stem-cell transplantation in patients with chronic granulomatous disease: a prospective multicentre study. Lancet 2013; published online Oct 23. http://dx.doi.org/10.1016/S1040-6737(13)62069-3. Horwitz ME, Barrett AJ, Brown MR, et al. Treatment of chronic granulomatous disease with nonmyeloablative conditioning and a T-cell-depleted hematopoietic allograft. N Engl J Med 2001; 344: 881–88.
9
10
11
Iannone R, Casella JF, Fuchs EJ, et al. Results of minimally toxic nonmyeloablative transplantation in patients with sickle cell anemia and thalassemia. Biol Blood Marrow Transplant 2003; 9: 519–28. Bradley MB, Satwani P, Baldinger L, et al. Reduced intensity allogeneic umbilical cord blood transplantation in children and adolescent recipients with malignant and non-malignant disease. Bone Marrow Transplant 2007; 40: 621–31. Kamani NR, Walters MC, Carter S, et al. Unrelated donor cord blood transplantation for children with severe sickle cell disease: results of one cohort from the phase II study from the Blood and Marrow Transplant Clinical Trials Network (BMT CTN). Biol Blood Marrow Transplant 2012; 18: 1265–72.
Anwar Amro/Stringer/AFP/Getty Images
Research and activism for tobacco control in the Arab world
Published Online January 20, 2014 http://dx.doi.org/10.1016/ S0140-6736(13)62381-8 See Series pages 449 and 458 See Series Lancet 2014; 383: 343–55, 356–67, and 368–81
392
Smoking rates in the Arab world are some of the highest worldwide.1 The epidemic is characterised by high and increasing rates of smoking in men and a dramatic reemergence of waterpipe smoking, especially in young people (aged 13–24 years) and women. Although 19 of the 22 Arab countries have ratified the Framework Convention for Tobacco Control, implementation and enforcement of its provisions has been slow, weak, and ineffective in most countries.2 Advocacy for a tobacco control agenda that protects and promotes public health has been successful in other regions of the world.3–6 Active engagement and collaboration between various sectors committed to tobacco control has resulted in some success stories in the Arab world as well. Reports have outlined crucial elements for successful tobacco control advocacy and policy change,7,8 but in this piece we emphasise those most relevant to the Arab world on the basis of our own experience. First is the need for local evidence to support advocacy and policy.9,10 This element is particularly important to provide context-specific counter-arguments to those brought about by opposing forces to local policy change, such as advertising agencies or multinational tobacco companies.11,12 Second is the importance of partnerships between academics and motivated and passionate activists, who believe in tobacco control and have strong resolve to achieve change. Partners complement each other in the skills they bring to the partnership, and widen the circle of support. In Lebanon, for example, such collaborations were instrumental in the advancement of the clean indoor air policy, and involved academics working with communication experts with strong contacts with local media, and experts in bold, confrontational advocacy techniques such as stunt flash mobs and direct action.
A key element in the success of these partnerships, in our experience, was the promotion of one voice and one message. Opposing forces, naturally, were keen to promote the need for smoking areas rather than smoke-free public spaces, and the need for gradual implementation and enforcement. Promoting one voice—backed by evidence from around the world— ensured success in counteracting these suggestions. The third element is the importance of perseverance and audacity in the face of overwhelming opposition. This approach usually requires relentless day-in, dayout focus on the target to be achieved by the tobacco control community, and the ability not to get entangled with the sideshows put on by the opposition to derail the discourse towards their own agenda (eg, freedom of choice, consumer rights, and loss of revenues). It also means the ability to engage in various channels and media to maintain public pressure and support for tobacco control policies. Fourth is the importance of having a very good understanding of power relations and structure relevant to each country or context and each tobacco control policy. In particular, tobacco control partners need to be savvy about power relations and dynamics locally, as well as their external connections with the international tobacco industry. Exposing such connections, at the right time, can provide the key catalyst for policy change. Fifth is the value of developing personal relationships with stakeholders along the way, who understand the main rationale for tobacco control and are ready to go out of their way to support tobacco control work. For example, maintaining a strong relationship with the media can be crucial in advocacy for tobacco control policies. Additionally, personal relationships with supportive politicians can guide tobacco control www.thelancet.com Vol 383 February 1, 2014
Comment
advocacy by providing access to confidential business or political deliberations. The final element is to be willing to let others take credit. This action requires an understanding that each success provides a springboard to the next, and that long-enduring partnerships require giving credit to other partners—especially those that are not public health professionals—to keep them motivated and engaged. In the end, the most important success is the passage and implementation of a strong tobacco control law. The uniqueness of each society and each tobacco control policy needs a critical analysis of what works by those familiar with the intricacies of the local context. This approach is of paramount importance for the effective adaptation of global strategies to local settings. In the Arab world, where public health policies suffer from chronic weakness, partnerships need to be created to provide the needed public pressure for such policies. Such partnerships can be built around academic and advocacy cooperation and involve local, regional, and international professional networks. This approach bodes well for a strong unified voice and action for tobacco control and public health in the Arab world. *Rima Nakkash, Rima Afifi, Wasim Maziak Department of Health Promotion and Community Health, WHO Collaborating Center for Health Promotion and Behavioral Sciences, Faculty of Health Sciences, American University of Beirut,
Beirut 1107 2020, Lebanon (RN, RA); Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA (WM); and Syrian Center for Tobacco Studies, Aleppo, Syria (WM) [email protected] We declare that we have no conflicts of interest. 1
2
3 4
5
6 7 8
9
10
11 12
Warren CW, Jones NR, Peruga A, et al, for the Centers for Disease Control and Prevention (CDC). Global youth tobacco surveillance, 2000–2007. MMWR Surveill Summ 2008; 57: 1–28. Maziak W, Nakkash R, Bahelah R, Husseini A, Fanous N, Eissenberg T. Tobacco in the Arab world: old and new epidemics amidst policy paralysis. Health Policy Plan 2013; published online Aug 19. DOI:10.1093/heapol/czt055. MacKay J, Ritthiphakdee B, Reddy S. Tobacco control in Asia. Lancet 2013; 381: 1581–87. Champagne BM, Sebrié E, Schoj V. The role of organized civil society in tobacco control in Latin America and the Caribbean. Salud Publica Mex 2010; 52 (suppl 2): S330–39. Novotny TE, Mamudu HM. Health, nutrition and population (HNP) discussion paper. Progression of tobacco control policies: lessons from the United States and implications for global action. May, 2008. http://siteresources.worldbank. org/healthnutritionandpopulation/resources/281627-1095698140167/ novotnypoliticaleconomy.pdf (accessed Oct 10, 2013). Chapman S, Wakefield M. Tobacco control advocacy in Australia: reflections on 30 years of progress. Health Educ Behav 2001; 28: 274–89. MacKay J. The role of research on the development and implementation of policy. Nicotine Tob Res 2013; 15: 757–60. Orton L, Lloyd-Williams F, Taylor-Robinson D, O’Flaherty M, Capewell S. The use of research evidence in public health decision making processes: systematic review. PLoS One 2011; 6: e21704. Salti N, Chaaban J, Nakkash R, Alaouie H. The effect of taxation on tobacco consumption and public revenue in Lebanon. Tob Control 2013; published online June 20. DOI:10.1136/tobaccocontrol-2012-050703. Nakkash R, Khalil J, Chaaya M, Afifi RA. Building research evidence for policy advocacy: a qualitative evaluation of existing smoke free policies in Lebanon. Asia Pac J Public Health 2010; 22 (suppl): 168S–74S. Nakkash R, Lee K. Smuggling as the “key to a combined market”: British American tobacco in Lebanon. Tob Control 2008; 17: 324–31. Nakkash R, Lee K. The tobacco industry’s thwarting of marketing restrictions and health warnings in Lebanon. Tob Control 2009; 18: 310–16.
The making of the Lancet Series on health in the Arab world During a visit to Lebanon in July, 2011, Lancet Editor-inChief Richard Horton invited us to prepare the Lancet Series on Health in the Arab World: a View from Within. The invitation fell on receptive ears, and came at the right time. Earlier that year, four of us had finished collaborating on an edited volume entitled Public Health in the Arab World,1 with more than 80 contributing scholars, mostly from the region, and some international scholars. Conducting research to provide evidence that can contribute to improving health in a region engulfed in war and ongoing turmoil is not an easy matter. Researchers in our region must struggle with and overcome several constraints, including heavy teaching loads and institution-building priorities, leaving little time dedicated to research; absence of institutional www.thelancet.com Vol 383 February 1, 2014
incentives and support for conducting quality research; dearth of publicly available datasets; and absence of funding and government commitment to encourage research. But above all, we must sometimes confront enormous challenges brought about by wars and conflicts, injustice, fragmentation, insecurities, and uncertainties, which can at times suddenly dwarf our research agendas and make them irrelevant. In response to this predicament and to remain engaged, productive, and relevant we learned the importance of working in teams and building networks to support each other. And so, over the past decade, a group of us came together on the basis of a common understanding of the importance of the social and political contexts of health; an interest in developing frameworks of analysis that
Published Online January 20, 2014 http://dx.doi.org/10.1016/ S0140-6736(13)62370-3 See Series pages 449 and 458 See Series Lancet 2014; 383: 343–55, 356–67, and 368–81
393
6
7
8
Bhatia S. Long-term health impacts of hematopoietic stem cell transplantation inform recommendations for follow-up. Expert Rev Hematol 2011; 4: 437–52. Güngör T, Teira P, Slatter M, et al, on behalf of the Inborn Errors Working Party of the European Society for Blood and Marrow Transplantation. Reduced-intensity conditioning and HLA-matched haemopoietic stem-cell transplantation in patients with chronic granulomatous disease: a prospective multicentre study. Lancet 2013; published online Oct 23. http://dx.doi.org/10.1016/S1040-6737(13)62069-3. Horwitz ME, Barrett AJ, Brown MR, et al. Treatment of chronic granulomatous disease with nonmyeloablative conditioning and a T-cell-depleted hematopoietic allograft. N Engl J Med 2001; 344: 881–88.
9
10
11
Iannone R, Casella JF, Fuchs EJ, et al. Results of minimally toxic nonmyeloablative transplantation in patients with sickle cell anemia and thalassemia. Biol Blood Marrow Transplant 2003; 9: 519–28. Bradley MB, Satwani P, Baldinger L, et al. Reduced intensity allogeneic umbilical cord blood transplantation in children and adolescent recipients with malignant and non-malignant disease. Bone Marrow Transplant 2007; 40: 621–31. Kamani NR, Walters MC, Carter S, et al. Unrelated donor cord blood transplantation for children with severe sickle cell disease: results of one cohort from the phase II study from the Blood and Marrow Transplant Clinical Trials Network (BMT CTN). Biol Blood Marrow Transplant 2012; 18: 1265–72.
Anwar Amro/Stringer/AFP/Getty Images
Research and activism for tobacco control in the Arab world
Published Online January 20, 2014 http://dx.doi.org/10.1016/ S0140-6736(13)62381-8 See Series pages 449 and 458 See Series Lancet 2014; 383: 343–55, 356–67, and 368–81
392
Smoking rates in the Arab world are some of the highest worldwide.1 The epidemic is characterised by high and increasing rates of smoking in men and a dramatic reemergence of waterpipe smoking, especially in young people (aged 13–24 years) and women. Although 19 of the 22 Arab countries have ratified the Framework Convention for Tobacco Control, implementation and enforcement of its provisions has been slow, weak, and ineffective in most countries.2 Advocacy for a tobacco control agenda that protects and promotes public health has been successful in other regions of the world.3–6 Active engagement and collaboration between various sectors committed to tobacco control has resulted in some success stories in the Arab world as well. Reports have outlined crucial elements for successful tobacco control advocacy and policy change,7,8 but in this piece we emphasise those most relevant to the Arab world on the basis of our own experience. First is the need for local evidence to support advocacy and policy.9,10 This element is particularly important to provide context-specific counter-arguments to those brought about by opposing forces to local policy change, such as advertising agencies or multinational tobacco companies.11,12 Second is the importance of partnerships between academics and motivated and passionate activists, who believe in tobacco control and have strong resolve to achieve change. Partners complement each other in the skills they bring to the partnership, and widen the circle of support. In Lebanon, for example, such collaborations were instrumental in the advancement of the clean indoor air policy, and involved academics working with communication experts with strong contacts with local media, and experts in bold, confrontational advocacy techniques such as stunt flash mobs and direct action.
A key element in the success of these partnerships, in our experience, was the promotion of one voice and one message. Opposing forces, naturally, were keen to promote the need for smoking areas rather than smoke-free public spaces, and the need for gradual implementation and enforcement. Promoting one voice—backed by evidence from around the world— ensured success in counteracting these suggestions. The third element is the importance of perseverance and audacity in the face of overwhelming opposition. This approach usually requires relentless day-in, dayout focus on the target to be achieved by the tobacco control community, and the ability not to get entangled with the sideshows put on by the opposition to derail the discourse towards their own agenda (eg, freedom of choice, consumer rights, and loss of revenues). It also means the ability to engage in various channels and media to maintain public pressure and support for tobacco control policies. Fourth is the importance of having a very good understanding of power relations and structure relevant to each country or context and each tobacco control policy. In particular, tobacco control partners need to be savvy about power relations and dynamics locally, as well as their external connections with the international tobacco industry. Exposing such connections, at the right time, can provide the key catalyst for policy change. Fifth is the value of developing personal relationships with stakeholders along the way, who understand the main rationale for tobacco control and are ready to go out of their way to support tobacco control work. For example, maintaining a strong relationship with the media can be crucial in advocacy for tobacco control policies. Additionally, personal relationships with supportive politicians can guide tobacco control www.thelancet.com Vol 383 February 1, 2014
Comment
advocacy by providing access to confidential business or political deliberations. The final element is to be willing to let others take credit. This action requires an understanding that each success provides a springboard to the next, and that long-enduring partnerships require giving credit to other partners—especially those that are not public health professionals—to keep them motivated and engaged. In the end, the most important success is the passage and implementation of a strong tobacco control law. The uniqueness of each society and each tobacco control policy needs a critical analysis of what works by those familiar with the intricacies of the local context. This approach is of paramount importance for the effective adaptation of global strategies to local settings. In the Arab world, where public health policies suffer from chronic weakness, partnerships need to be created to provide the needed public pressure for such policies. Such partnerships can be built around academic and advocacy cooperation and involve local, regional, and international professional networks. This approach bodes well for a strong unified voice and action for tobacco control and public health in the Arab world. *Rima Nakkash, Rima Afifi, Wasim Maziak Department of Health Promotion and Community Health, WHO Collaborating Center for Health Promotion and Behavioral Sciences, Faculty of Health Sciences, American University of Beirut,
Beirut 1107 2020, Lebanon (RN, RA); Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA (WM); and Syrian Center for Tobacco Studies, Aleppo, Syria (WM) [email protected] We declare that we have no conflicts of interest. 1
2
3 4
5
6 7 8
9
10
11 12
Warren CW, Jones NR, Peruga A, et al, for the Centers for Disease Control and Prevention (CDC). Global youth tobacco surveillance, 2000–2007. MMWR Surveill Summ 2008; 57: 1–28. Maziak W, Nakkash R, Bahelah R, Husseini A, Fanous N, Eissenberg T. Tobacco in the Arab world: old and new epidemics amidst policy paralysis. Health Policy Plan 2013; published online Aug 19. DOI:10.1093/heapol/czt055. MacKay J, Ritthiphakdee B, Reddy S. Tobacco control in Asia. Lancet 2013; 381: 1581–87. Champagne BM, Sebrié E, Schoj V. The role of organized civil society in tobacco control in Latin America and the Caribbean. Salud Publica Mex 2010; 52 (suppl 2): S330–39. Novotny TE, Mamudu HM. Health, nutrition and population (HNP) discussion paper. Progression of tobacco control policies: lessons from the United States and implications for global action. May, 2008. http://siteresources.worldbank. org/healthnutritionandpopulation/resources/281627-1095698140167/ novotnypoliticaleconomy.pdf (accessed Oct 10, 2013). Chapman S, Wakefield M. Tobacco control advocacy in Australia: reflections on 30 years of progress. Health Educ Behav 2001; 28: 274–89. MacKay J. The role of research on the development and implementation of policy. Nicotine Tob Res 2013; 15: 757–60. Orton L, Lloyd-Williams F, Taylor-Robinson D, O’Flaherty M, Capewell S. The use of research evidence in public health decision making processes: systematic review. PLoS One 2011; 6: e21704. Salti N, Chaaban J, Nakkash R, Alaouie H. The effect of taxation on tobacco consumption and public revenue in Lebanon. Tob Control 2013; published online June 20. DOI:10.1136/tobaccocontrol-2012-050703. Nakkash R, Khalil J, Chaaya M, Afifi RA. Building research evidence for policy advocacy: a qualitative evaluation of existing smoke free policies in Lebanon. Asia Pac J Public Health 2010; 22 (suppl): 168S–74S. Nakkash R, Lee K. Smuggling as the “key to a combined market”: British American tobacco in Lebanon. Tob Control 2008; 17: 324–31. Nakkash R, Lee K. The tobacco industry’s thwarting of marketing restrictions and health warnings in Lebanon. Tob Control 2009; 18: 310–16.
The making of the Lancet Series on health in the Arab world During a visit to Lebanon in July, 2011, Lancet Editor-inChief Richard Horton invited us to prepare the Lancet Series on Health in the Arab World: a View from Within. The invitation fell on receptive ears, and came at the right time. Earlier that year, four of us had finished collaborating on an edited volume entitled Public Health in the Arab World,1 with more than 80 contributing scholars, mostly from the region, and some international scholars. Conducting research to provide evidence that can contribute to improving health in a region engulfed in war and ongoing turmoil is not an easy matter. Researchers in our region must struggle with and overcome several constraints, including heavy teaching loads and institution-building priorities, leaving little time dedicated to research; absence of institutional www.thelancet.com Vol 383 February 1, 2014
incentives and support for conducting quality research; dearth of publicly available datasets; and absence of funding and government commitment to encourage research. But above all, we must sometimes confront enormous challenges brought about by wars and conflicts, injustice, fragmentation, insecurities, and uncertainties, which can at times suddenly dwarf our research agendas and make them irrelevant. In response to this predicament and to remain engaged, productive, and relevant we learned the importance of working in teams and building networks to support each other. And so, over the past decade, a group of us came together on the basis of a common understanding of the importance of the social and political contexts of health; an interest in developing frameworks of analysis that
Published Online January 20, 2014 http://dx.doi.org/10.1016/ S0140-6736(13)62370-3 See Series pages 449 and 458 See Series Lancet 2014; 383: 343–55, 356–67, and 368–81
393
