When evidence is not enough: Political, legal, and coalition determinants of tobacco standardized packaging adoption in Brazil and globally
ABSTRACTBackground Tobacco use remains one of the leading preventable causes of death worldwide, and reducing smoking continues to be a central public health priority. The WHO Framework Convention on Tobacco Control (WHO FCTC) has supported the diffusion of major evidence-based tobacco control measures, including tobacco standardized packaging (SP), a policy designed to reduce the marketing appeal of tobacco products, strengthen health warnings, and limit the pack’s function as advertising. Although evidence supporting SP has grown, adoption has been slow and uneven, particularly in low- and middle-income countries (LMICs). This uneven uptake highlights a broader policy challenge: how evidence and political commitment are translated through legal, institutional, and strategic contexts into adoption, redesign, or prolonged non-decision. Purpose The aims of this dissertation are: 1. To synthesize the global evidence on barriers and facilitators to tobacco SP adoption; 2. To examine how barriers and facilitators became consequential through agenda control, constitutional filtering, bicameral sequencing, and venue gatekeeping across Brazil’s Congress; and 3. To analyze how competing coalitions, their beliefs, and their strategic resources shaped SP outcomes across Brazil’s legislative venues. Methods In the first paper, I conducted a global systematic review of peer-reviewed studies on barriers and facilitators to tobacco SP adoption. I searched PubMed, Embase, and Web of Science for studies published in English between January 2005 and October 2025, screened records using predefined inclusion criteria, and extracted data into a framework integrating the Policy Dystopia Model, Multiple Streams Theory, and Strategic Action Typologies. In the second paper, I conducted a single-case, theory-guided process-tracing study of Brazil’s SP trajectory across the Federal Senate and the Chamber of Deputies. First, I reconstructed the dated legislative chronology from official congressional logs. I then analyzed official process documents and semi-structured interviews to identify where barriers and facilitators entered the process, how they operated through specific legislative mechanisms, and where leverage concentrated at decision-proximate institutional outputs. In the third paper, I used a single-case theory-guided qualitative design to examine Brazil’s policy process through the Advocacy Coalition Framework paired with an influence pathway perspective. Using the legislative action dataset, official documents, and semi-structured interviews, I applied thematic content analysis to evaluate how coalition beliefs and coalition resources shaped coalition influence across legislative venues, with influence conceptualized as a pathway from transmission to reception to institutional response. Results Study One The Global review identified 967 records, of which 41 met the inclusion criteria. The findings showed that barriers to SP were most often driven by private-sector activity, especially legal threats, lobbying, and framing strategies, while facilitators were most often driven by government action, including legal preparedness, ministry coordination, and strategic use of evidence. The evidence base was concentrated in high-income countries (HICs) and research relied heavily on secondary or descriptive designs. Study Two The process-tracing study showed that the most important changes happened at the legislative points where formal decisions could move, narrow, or stall the bill, not simply where debate or activity accumulated. In Brazil’s Congress, the proposal first gained momentum through favorable movement in Senate committees, but over a decade-long legislative process it was narrowed and remains stalled. In the Senate, policy champions and procedural leadership helped move the bill forward while SP was still included. Constitutional review transformed the outcome through a venue-specific mechanism: the committee rapporteur applied a trademark essential core standard that treated de-branding as extinguishing rather than regulating trademark expression, producing a binding redesign that removed SP's de-branding provision even though SP supporters had entered constitutional review with a substantively robust legal defense. The bill continued forward without its original SP model. In plenary, senators blocked efforts to send the bill to an agriculture-oriented committee, but final Senate approval locked in the narrower version and made it harder to restore SP later. In the Chamber of Deputies, a more complex committee route, attachment to other bills, and rapporteur gatekeeping kept the proposal from advancing, producing prolonged non-decision and institutional stalling. Study Three The coalition influence analysis showed that two competing coalitions shaped the fate of SP in Brazil: a public health coalition that supported stronger tobacco regulation and an opposing coalition that defended tobacco-sector economic interests and brand-related rights. Across the legislative process, both coalitions remained stable in their policy core beliefs. What changed was which decision rule each venue treated as operative. In health-oriented Senate committees, public-health primacy aligned with the venue mandate and supported bill advancement. At constitutional review, however, both coalitions entered a mandatory venue with legitimate constitutional claims, and the decisive issue became the rapporteur’s authority to select which constitutional standard governed the output. When disagreements involved more negotiable design details, limited compromise was possible. The study also showed that compromise operated not only through secondary design adjustments but through trade-offs across provisions of the bundled bill, with SP conceded to preserve movement on companion measures. On resources, the study showed that coalition resources mattered most at decision-proximate nodes where legislative outputs became binding. In the Senate, the pro-SP coalition was better able to combine technical expertise, legal support, political access, and policy champions to move its arguments from transmission to reception and institutional response. In the Chamber of Deputies, that balance shifted into a widening resource asymmetry. As a result, coalition activity continued, but it more often remained limited to transmission or partial reception without legislative response, contributing to prolonged drift and non-decision. The Chamber stage also showed that anti-coalition influence worked less through persuasion than through structural control over gatekeeping positions and the weakening of pro-coalition coordination infrastructure. Conclusions Taken together, these studies show that tobacco SP adoption depends not only on strong evidence and political commitment, but on how evidence moves through the legal, political, and institutional systems that produce legislation. Globally, progress is shaped by recurring patterns of industry opposition and the degree to which governments are legally prepared, institutionally coordinated, and backed by organized public health coalitions. In Brazil, those dynamics became consequential at specific legislative decision points — which committees reviewed the bill, who was assigned to write committee reports, how the bill moved between the two houses of Congress, and whether organized support was present at each critical moment. The dissertation's central finding is that SP did not fail through a single decisive defeat. It was progressively narrowed and eventually stalled through a compounding sequence of institutional decisions, each of which appeared formally neutral while the bill remained technically active throughout. Three theoretical contributions emerge. First, when both sides of a policy dispute hold equally legitimate constitutional claims within the same mandatory review body, the outcome is determined not by argument quality but by which legal standard the assigned reviewer chooses to apply — a condition existing policy process theory does not address. Second, when a health reform travels alongside other measures in a bundled bill, coalitions may concede one provision to protect others, a form of compromise the existing literature does not fully account for. Third, one of the most consequential tactics used against the bill was not lobbying or litigation but the deliberate dismantling of the government body coordinating public health advocacy — removing the opponent's capacity to act rather than defeating their arguments. Advancing SP in comparable settings requires assessing legislative routes before bill introduction, preparing legal arguments at early committee stages rather than only at constitutional review, protecting government health coordination bodies, cultivating political champions specifically in the revising chamber, and monitoring procedural inaction as an early indicator that a bill is being stalled rather than openly defeated.
Coalitions, Gatekeeping, Health Policy, Influence, Standardized Packaging, Tobacco
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