Open Access Highly Accessed Open Badges Research article

Policy guidance on threats to legislative interventions in public health: a realist synthesis

Geoff Wong1*, Ray Pawson2 and Lesley Owen3

Author Affiliations

1 NIHR Clinical Lecturer, Research Department of Primary Care and Population Health, UCL, Upper Third Floor, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK

2 Professor of Social Research Methodology, School of Sociology and Social Policy, University of Leeds, Leeds, LS2 9JT, UK

3 Senior Analyst, National Institute for Health and Clinical Excellence (NICE), MidCity Place, 71 High Holborn, London, WC1V 6NA, UK

For all author emails, please log on.

BMC Public Health 2011, 11:222  doi:10.1186/1471-2458-11-222

Published: 10 April 2011



Legislation is one of the most powerful weapons for improving population health and is often used by policy and decision makers. Little research exists to guide them as to whether legislation is feasible and/or will succeed. We aimed to produce a coherent and transferable evidence based framework of threats to legislative interventions to assist the decision making process and to test this through the 'case study' of legislation to ban smoking in cars carrying children.


We conceptualised legislative interventions as a complex social interventions and so used the realist synthesis method to systematically review the literature for evidence. 99 articles were found through searches on five electronic databases (MEDLINE, HMIC, EMBASE, PsychINFO, Social Policy and Practice) and iterative purposive searching. Our initial searches sought any studies that contained information on smoking in vehicles carrying children. Throughout the review we continued where needed to search for additional studies of any type that would conceptually contribute to helping build and/or test our framework.


Our framework identified a series of transferable threats to public health legislation. When applied to smoking bans in vehicles; problem misidentification; public support; opposition; and enforcement issues were particularly prominent threats. Our framework enabled us to understand and explain the nature of each threat and to infer the most likely outcome if such legislation were to be proposed in a jurisdiction where no such ban existed.

Specifically, the micro-environment of a vehicle can contain highly hazardous levels of second hand smoke. Public support for such legislation is high amongst smokers and non-smokers and their underlying motivations were very similar - wanting to practice the Millian principle of protecting children from harm. Evidence indicated that the tobacco industry was not likely to oppose legislation and arguments that such a law would be 'unenforceable' were unfounded.


It is possible to develop a coherent and transferable evidence based framework of the ideas and assumptions behind the threats to legislative intervention that may assist policy and decision makers to analyse and judge if legislation is feasible and/or likely to succeed.