title: Banning shisha smoking in public places in Iran: an advocacy coalition framework perspective on policy process and change.
abstract: BACKGROUND
  Shisha smoking is a widespread custom in Iran with a rapidly growing prevalence especially among the youth. In this article, we analyze the policy process of enforcing a federal/state ban on shisha smoking in all public places in Kerman Province, Iran. Guided by the Advocacy Coalition Framework (ACF), we investigate how a shisha smoking ban reached the political agenda in 2011, how it was framed by different policy actors, and why no significant breakthrough took place despite its inclusion on the agenda.
  
  
  METHODS
  We conducted a qualitative study using a case study approach. Two main sources of data were employed: face-to-face in-depth interviews and document analysis of key policy texts. We interviewed 24 policy actors from diverse sectors. A qualitative thematic framework, incorporating both inductive and deductive analyses, was employed to analyze our data.
  
  
  RESULTS
  We found that the health sector was the main actor pushing the issue of shisha smoking onto the political agenda by framing it as a public health risk. The health sector and its allies advocated enforcement of a federal law to ban shisha smoking in all public places including teahouses and traditional restaurants whereas another group of actors opposed the ban. The pro-ban group was unable to neutralize the strategies of the anti-ban group and to steer the debate towards the health harms of shisha smoking. Our analysis uncovers three main reasons behind the policy stasis: lack of policy learning due to lack of agreement over evidence and related analytical conflicts between the two groups linked to differences in core and policy beliefs; the inability of the pro-ban group to exploit opportunities in the external policy subsystem through generating stronger public support for enforcement of the shisha smoking ban; and the nature of the institutional setting, in particular the autocratic governance of CHFS which contributed to a lack of policy learning within the policy subsystem.
  
  
  CONCLUSIONS
  Our research demonstrated the utility of ACF as a theoretical framework for analyzing the policy process and policy change to promote tobacco control. It shows the importance of accounting for policy actors' belief systems and issue-framing in understanding how some issues get more prominence in the policy-making process than others. Our findings further indicate a need for significant resources employed by the state through public awareness campaigns to change public perceptions of shisha smoking in Iran which is a deeply anchored cultural practice.
authors.affiliation: School of Public Policy, University of Calgary, Calgary, AB, Canada.|Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.|School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Akram
authors.initials: A
authors.lastname: Khayatzadeh-Mahani
authors.affiliation: EHESP School of Public Health, Sorbonne Paris Cité, Rennes, France.|CNRS, UMR 6051, Arènes, team 1: Social and health care policies -population and inequality, Rennes, France.
authors.forename: Eric
authors.initials: E
authors.lastname: Breton
authors.affiliation: School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Arne
authors.initials: A
authors.lastname: Ruckert
authors.affiliation: School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.|Canada Research Chair, Globalization and Health Equity Research Unit, University of Ottawa, Ottawa, ON, Canada.|Faculty of Health Sciences, Flinders University of South Australia, Adelaide, Australia.
authors.forename: Ronald
authors.initials: R
authors.lastname: Labonté
mesh_terms: D003254:Consumer Advocacy; D006291:Health Policy / Q000331:legislation & jurisprudence; D007492:Iran; D011050:Policy Making; D036301:Qualitative Research; D012907:Smoking / Q000331:legislation & jurisprudence*; D000074606:Smoking Prevention; D000075387:Smoking Water Pipes
keywords: Advocacy Coalition Framework (ACF); Iran; policy change; policy process; shisha smoking; tobacco control