RESEARCH AND PRACTICE

Global Tobacco Control Diffusion: The Case of the Framework Convention on Tobacco Control
Heather L. Wipi, PhD, Kayo Fujimoto, PhD, and Thomas W. Valente, PhD

Although the risks of tobacco smoking have been known for decades, the pandemic of tobacco use continues. There are now an estimated 1.3 billion smokers worldwide, along with millions more who use various oral tobacco products.1 Tobacco is the leading cause of preventable death worldwide, resulting in about 6 million deaths per year.2 Despite great progress in tobacco control, primarily in North America and Western Europe, the number of tobacco-attributable deaths is projected to grow substantially during this century, especially in low- and middle-income countries. In 1999, in recognition of the shift and growth in tobacco consumption and the potential for an enormous future burden of death and disease, the World Health Organization (WHO) member states initiated formal negotiations on an international treaty aimed at reducing this global threat. The Intergovernmental Negotiating Body (INB), which was charged with negotiating the text of the treaty, held 6 formal negotiating sessions in Geneva between 2000 and 2003. Over 170 states sent at least 1 delegate to 1 of the INB sessions. Scientic experts and representatives of advocacy networks also attended the negotiations, where they held seminars on technical aspects of the convention and distributed information to delegates. GLOBALink, an online network internationally recognized for facilitating communication between tobacco control advocates, was one such network.3 In addition to the INB sessions, countless regional negotiating sessions and technical conferences were convened during the period. In May 2003, the 56th World Health Assembly unanimously adopted the WHO Framework Convention on Tobacco Control (FCTC).4 The key provisions include a comprehensive ban on tobacco advertising, promotion, and sponsorship; a ban on misleading descriptors intended to convince smokers that certain products are safer than standard cigarettes (for example, the term lights in Marlboro Lights); and

Objectives. We analyzed demographic and social network variables associated with the timing of ratication of the Framework Convention on Tobacco Control (FCTC). Methods. We compiled a 2-mode data set that recorded country participation in FCTC negotiations, as well as the number of individuals per country per year who joined an online tobacco control network. We used logistic regression analysis of these 2 data sets along with geographic location to determine whether exposure to prior FCTC adoptions was associated with a countrys likelihood of adoption. Results. In the logistic regression analysis, higher income and more nongovernmental organizations (NGOs) involved in the Framework Convention Alliance (a network dedicated to the FCTC) were associated with being among the earliest adopters (for income, adjusted odds ratio [AOR] = 2.41; 95% condence interval [CI] = 1.55; for NGOs, AOR = 1.66; 95% CI = 1.26, 2.17) or among early adopters (for income, AOR = 1.42; 95% CI = 1.09, 1.84; for NGOs, AOR = 1.23; 95% CI = 1.03, 1.45). Network exposure and event history analysis showed that in addition to income, the likelihood of adoption increased with increasing afliation exposure to FCTC adopters through GLOBALink (an online network facilitating communication between tobacco control advocates). Conclusions. Public health programs should include a plan for creating opportunities for network interaction; otherwise, adoption and diffusion will be delayed and the investments in public health policy greatly diminished. (Am J Public Health. 2010;100:12601266. doi:10.2105/AJPH.2009.167833)

a mandate to place rotating warnings that cover at least 30% of tobacco packaging. The FCTC also encourages countries to implement smokefree workplace laws, address tobacco smuggling, and increase tobacco taxes. The FCTC entered into force on February 27, 2005, 90 days after the 40th member state ratied the treaty. Further ratications or its legal equivalent (acceptance or approval) continued over the next 4 years. As of May 2009, 168 countries were party to the treaty. The institutionalization of tobacco control within the WHO and the subsequent ratication of the FCTC by nearly all WHO member states provides an opportunity to analyze the system and network dynamics that facilitate global tobacco control diffusion. Diffusion refers to the process by which an innovation is communicated through certain channels over time among members of a social system.5 The premise, which has been conrmed by empirical research, is that

new ideas and practices spread through interpersonal contacts largely consisting of interpersonal communication.5,6 Other researchers have investigated specically how social networks provide the channels through which new ideas and practices, such as the FCTC, are spread.57 Given studies of diffusion in other contexts, we hypothesized that the global diffusion of the FCTC has been partly driven by interpersonal communication and networking developed throughout the negotiation of the FCTC and facilitated through existing global tobacco control networks. In other words, we hypothesized that the extent of a countrys participation in the FCTC negotiations and its citizens involvement in international tobacco control networks would be associated with early or late FCTC ratication. However, we also expected the predictability of these social network variables to be impacted to some extent by the structural and

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demographic aspects of states (e.g., location, population, income level, degree of political freedom, tobacco prevalence, and tobacco production). For example, a country with a high smoking prevalence may perceive tobacco control as more important and ratify sooner than a country with low prevalence. Conversely, a tobacco-producing and exporting country may view tobacco control as a threat to its nancial success and resist ratication. Here we analyzed the structural, demographic, and social network variables that led individual countries to ratify the FCTC when they did and made a rst attempt at specifying the driving forces behind global tobacco control diffusion.

METHODS
The timing of the adoption of the FCTC was measured as the day the country ratied the FCTC recoded to the month (coding adoption of the FCTC monthly made the data manageable). The ratication dates are available on the WHOs Tobacco Free Initiative Web site.8 In addition, 2 dummy variables were created to indicate the earliest adopters (rst 30 ratied, 15.5%) and the early adopters (rst 95 ratied, 49.2%). The decision to divide the countries by the rst 16% and rst 50% was based on past diffusion research that categorized adopters on the basis of time of adoption. According to Rogers, early adopters are the rst16% and early majority are the rst half.5 Several structural characteristics of the countries were obtained, including population,9 gross national income,9 degree of political freedom,10 tobacco production (in tons),11 and current male and female smoking prevalence.12

Alliance, a network dedicated to the FCTC in 2009. GLOBALink staff provided the GLOBALink annual membership database to H.L. W. in 2007. The specic dates for individual GLOBALink memberships were not available and were undoubtedly scattered throughout the year. Consequently, memberships were updated as of December for each year. Framework Convention Alliance membership was recorded from the Framework Convention Alliance Web site in February 2009. Missing data were recoded to the mean. The number of countries for which we imputed missing values was 19 for gross national income, 70 for tobacco production, 31 for current male smoking prevalence, and 27 for current female smoking prevalence. Missing data analyses showed that the countries with any missing data (95 of 193) did not have differential adoption dates (odds ratio [OR] =1.00; P= .73), but had a lower level of log-scaled population (OR =0.83; P< .001), had a lower level of log-scaled tobacco production (OR= 0.76; P <.05), and had a lower level of NGOs participating in the Framework Convention Alliance (OR= 0.67; P <.001).

session or enrolled in GLOBALink. These coafliation matrices were used to generate vectors of afliation network exposures that measure the level of exposure to prior ratiers for each country. These matrices constitute the network within which the network diffusion analyses were conducted.7 The matrix and time of ratication variable were used to construct the 3 network exposure terms that were time varying (as each network partner adopted FCTC, it increased the focal countrys exposure). Timeconstant variables, the country characteristics, were also included in the analyses.7 The model tested in the event-history model (model 4) is based on country (i) and time (t):15 1 log itpit log Pryit 1 a 1 Pryit 1 k L X X 1 bj Xji 1 ql xil yt ;
j 1 l 1

Analysis Plan
To determine the factors associated with ratication of the FCTC, 4 regression models were estimated: (1) an ordinary least squared regression on time of ratication (reversed), (2) a logistic regression on being an earliest ratier (rst 15.5%), (3) a logistic regression on being an early ratier (rst 49.2%), and (4) an event-history model using logistic regression for the likelihood of adoption at each month. In the 3 logistic regressions (models 24), the numeric value representing the number of delegates participating in each INB per country and new members in GLOBALink per country per year were included. The 3 network diffusion terms calculated in the event-history model (model 4) were: (1) distance, (2) INB participation, and (3) GLOBALink membership. Reverse distances between country capitals were calculated, and this weight matrix was used to estimate contiguity effects. Afliation matrices of the INB and GLOBALink data for each country were transposed and postmultiplied to generate adjacency matrices.1416 Each element in the adjacency matrix represented the number of people from any 2 countries that jointly attended an INB

where yit is the binary indicator of FCTC ratication for country i (i =1, .., N) at time t, a is the intercept, bj is the parameter estimate for vectors of j (j =1, . . . ,k) characteristics (Xji) of country i, and ql is the parameter estimate for the time-varying network exposure variables [xil]yt. The xil network weight matrices are dened as one of the following xi matrices on the basis of distance (l =1), INB participation (l = 2), or GLOBALink (l = 3). Note that in this equation, xil was constant over time for the rst 2, but varied over time for GLOBALink. To estimate this equation, the generalized estimating equation was used with an autoregressive correlation structure with single lag and logit link function.17 Network gures were created with the software program Netdraw.18

RESULTS
Characteristics of the countries and the mean and median date of FCTC ratication globally and by region are shown in Table 1. The rst country to ratify the FCTC was Norway in June 2003 followed by Fiji in November 2003. FCTC ratication continued to spread (Figure 1) between countries over the next 6 years until ultimately only 33 of 193 countries (16.9%) resisted ratication of the FCTC (including the United States) during the time period. The mean and median dates of ratication for all ratifying countries were

Data Collection
Country participation in the negotiations was measured by the number of delegates sent to each INB session published in the ofcial list of participants. These are publicly available on the WHO Governing Bodies Web site.13 Increases in interaction between domestic and international advocates for tobacco control were measured through the number of new GLOBALink members per country per year between 1993 and 2006 and the number of nongovernmental organizations (NGOs) per country participating in the Framework Convention

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TABLE 1Characteristics of the Countries and the Mean and Median Date of Ratication of the Framework Convention on Tobacco Control (FCTC)
Value Date FCTC ratied Mean month (mean no. months until adoption globally) Median month (median no. months until adoption globally) Mean no. of months until adoption (from May 2003) Africa Americas Eastern Mediterranean Europe Southeast Asia Western Pacic Population size, no. (range) Income, % Low income Lower middle income Upper middle income High income Democracy, % Partially free Free Tobacco production, tons (range) Smoking prevalence, % Total Male Female No. tobacco NGOs, mean (range) No. participants in INB, mean (range) October 18, 2000 May 5, 2001 November 25, 2001 March 23, 2002 October 21, 2002 February 26, 2003 No. new GLOBALink members, mean (range) 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Note. INB = Intergovernmental Negotiating Body; NGO = nongovernmental organization.

March 2006 (35.4) November 2005 (31.0) 44.0 46.8 41.0 39.8 26.5 25.2 29 121 813 (81 0001 300 000 000) 26.50 27.50 20.60 25.40 30.80 46.70 54 406 (302 685 743) 23.70 34.80 13.10 1.57 (128) 2.62 (013) 2.83 (018) 3.09 (023) 2.97 (026) 3.30 (021) 3.58 (020) 0.26 (08) 0.08 (04) 0.05 (03) 0.28 (019) 1.85 (0147) 1.80 (0102) 1.02 (024) 3.03 (0176) 2.82 (0125) 3.78 (0219) 4.54 (0255) 3.69 (0250) 4.35 (0268) 4.09 (0199)

March 2006 and November 2005, respectively (approximately 2.5 years after the last INB session). Populous and less populous countries ratied the FCTC at approximately the same rate. The ratifying countries were nearly evenly split among the 4 income categories. Over 77% of the ratifying countries were considered politically free or partially free with an overall smoking prevalence of 23.7% (the smoking rate among men was considerably higher, 34.8%, than that among women, 13.1%). The number of delegates sent to the rst INB session (October 2000) ranged from 0 to 13 and averaged 2.62. By the nal INB session (February 2003), the number of delegates ranged from 0 to 26 and averaged 3.59. The average number of new GLOBALink members per country varied by year and generally increased, although not monotonically. By the end of 2006, membership in GLOBALink by country ranged from 0 to 1602, with a mean of 31.8. Countries in the Western Pacic and Southeast Asia had the earliest ratication times (25.2 months and 26.5 months, respectively), whereas Africa and the Americas were later (44.0 months and 46.8 months, respectively; Table 1). The results of the 4 models are presented in Table 2. The initial ordinary least squared regression on reversed time of ratication (to measure innovativeness) indicated that higher income level (B = 0.26; P < .01) and NGO membership in the Framework Convention Alliance (B = 0.27; P < .05) were the only variables associated with earlier adoption of the FCTC. The earliest (rst 15.5%) and early (rst 49.2%) adoption models using logistic regression analyses showed that income was again associated with being among the earliest adopters (adjusted odds ratio [AOR] = 2.41; 95% condence interval [CI] =1.55, 3.74) or among the early adopters (AOR =1.42; 95% CI =1.09, 1.84), as well as NGO membership in the Framework Convention Alliance (for earliest adopters, AOR =1.66; 95% CI =1.26, 2.17; for early adopters, AOR =1.23; 95% CI =1.03, 1.45). The event-history model included the network exposure terms and was an event history analysis using the generalized estimating equation in which each case in the data set (N = 6833 [34 193] average months

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Note. The y-axis represents the cumulative percentage of countries that have ratied the Framework Convention on Tobacco Control.

FIGURE 1Global diffusion of the Framework Convention on Tobacco Control.

until adoption by total countries) represented a country-year up to and including the year of ratication. Robust variance estimates were computed at the country level. Country characteristics represented time-constant variables and exposures were time-varying based on the ratication behavior of the countries coafliations. The analysis included the 33 never-ratied countries with time of ratication coded as the 72nd month. It is customary in diffusion research to recode the nonadopters as the last time of adoption provided the number of cases is not excessive. We repeated the analysis excluding

nonratifying countries with no change in the results. The results showed that exposure based on geography was positive but not statistically signicant (AOR =1.51; 95% CI = 0.33, 6.88). Exposure based on INB participation was positive but not statistically signicant (AOR = 2.11; 95% CI = 0.40, 11.06). Exposure based on increasing GLOBALink membership was positive and statistically signicant (AOR = 2.92; 95% CI =1.25, 6.78). The dummy variables for region indicated that the Western Pacic and Southeast Asia regions had earlier ratication dates (AOR = 4.77; 95% CI = 2.08, 10.92) than did Africa (AOR = 4.02; 95% CI =1.14, 14.13) and no other regions were statistically signicantly different from Africa. The AOR of 2.92 for the GLOBALink effect indicated that a country was nearly 3 times as likely to ratify the FCTC once their exposure to other ratiers via membership in GLOBALink reached 100%.

TABLE 2Regression Results for Adoption of the Framework Convention on Tobacco Control (FCTC)
OLS Regression, No. or B Total Log of population Log of income Democracy, partially free Democracy, free Tobacco production (in tons) Smoking prevalence, male Smoking prevalence, female No. NGOs in FCA Region (Africa ref) Americas Eastern Mediterranean Europe Southeast Asia Western Pacic No. new GLOBALink members Exposure based on INB Exposure based on GLOBALink Exposure based on geography 0.23 0.97 (0.95, 1.00) 1.00 (0.99,1.00) 1.09 (0.46, 2.58) 1.67 (0.48, 5.82) 1.19 (0.40, 3.55) 4.02* (1.14, 14.13) 4.77*** (2.08, 10.92) 1.05 (0.96, 1.15) 2.11 (0.40, 11.06) 2.92* (1.25, 6.78) 1.51 (0.33, 6.88) 193 0.12 0.26** 0.05 0.08 0.00 0.14 0.03 0.27* Logistic Regression Earliest Adoption, No. or AOR (95% CI) 193 0.92 (0.78, 1.08) 2.41*** (1.55, 3.74) 0.81 (0.24, 2.71) 0.78 (0.26, 2.35) 0.94 (0.76, 1.17) 1.02 (0.98, 1.06) 0.98 (0.93, 1.03) 1.66*** (1.26, 2.17) Logistic Regression Early Adoption, No. or AOR (95% CI) 193 0.93 (0.83, 1.04) 1.42** (1.09, 1.84) 0.70 (0.30, 1.63) 0.70 (0.31, 1.57) 1.04 (0.90, 1.21) 1.03 (1.00, 1.06) 1.00 (0.97, 1.04) 1.23* (1.03, 1.45) Event History Analysis Including Exposure, No. or AOR (95% CI) 6833 0.89 (0.79, 1.01) 1.17 (0.98, 1.41) 1.02 (0.65, 1.60) 0.87 (0.55, 1.37) 0.97 (0.89, 1.05) 1.00 (0.98, 1.02) 1.01 (0.98, 1.03) 1.00 (0.93, 1.08)

Note. AOR = adjusted odds ratio; CI = condence interval; FCA = Framework Convention Alliance; INB = Intergovernmental Negotiating Body; NGO = nongovernmental organization; OLS = ordinary least squared. *P < .05; **P < .01; ***P < .001, by the 2-tailed test.

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Note. Figure created using Netdraw.18 For example, Norway and India had at least 1 member (although not necessarily the same individual) who subscribed to GLOBALink for at least 9 years from 1993 to 2005. Conversely, Jordan and Palau only had 1 member during the same period. There were 5 outlying countries. Thicker lines indicate stronger links on GLOBALink.

FIGURE 2Network of the 30 countries that were the earliest to adopt the Framework Convention on Tobacco Control (rst 15.5% of all countries), with links indicating the magnitude of comembership on GLOBALink.

To illustrate these diffusion effects, we graphed the network of GLOBALink afliations for the earliest ratifying countries in Figure 2. This network was densely connected with few isolates (Naru, San Marino, and Seychelles). The core of the network contained countries from all over the globe but also clearly showed considerable coafliation on GLOBALink membership, which permitted communication about tobacco control. By contrast, the network of the 33 countries who have not yet ratied the FCTC are shown in Figure 3. In this network, 18 of the countries were isolates, indicating that they had no participants in GLOBALink. These analyses indicate that wealthier countries were more likely to ratify the FCTC earlier than were poorer countries, and ratication

dates differed by geographic region. The only other factor that inuenced adoption behavior was increasing membership in GLOBALink. Countries were more likely to ratify the FCTC after more of their citizens joined GLOBALink and as numbers of GLOBALink members from ratifying countries grew.

DISCUSSION
We analyzed the demographic and social network variables that led countries to ratify the FCTC at the time that they did. We compiled a 2-mode data set that recorded country participation in the negotiation of the FCTC. We also recorded the number of individuals by country who joined GLOBALink, an interactive online network created to

support tobacco control advocacy. These 2 data sets, along with physical location (latitude and longitude), were used to determine whether exposure to FCTC-related information and prior FCTC adoptions was associated with a countrys likelihood of ratication. The initial diffusion of FCTC ratication was not particularly rapid. The rst year consisted of a few scattered countries, none particularly populous, ratifying the FCTC. The evidence shows that contiguity was not a major factor in these early ratications. Thus, the evidence does not indicate that countries that ratied early served as role models to which other countries could readily point as motivations for FCTC ratication. The initial delay in ratication may have been a result of the fact that ratication required the completion of

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Note. Figure created using Netdraw.18 There were 18 outlying countries. Thicker lines indicate stronger links on GLOBALink.

FIGURE 3Network of the 33 countries that did not adopt the Framework Convention on Tobacco Control, with links indicating the magnitude of comembership on GLOBALink.

domestic policy processes. Given competing priorities and legislative schedules, it may simply have been impossible for some countries to ratify any quicker than they did. There was an increase in the rate of adoption in years 2 through 4, after which it leveled off. In retrospect, we can see that the FCTC is among the quickest treaties to enter into force, and has become among the most widely ratied treaties in existence. Most country attribute variables did not have a signicant effect on time of ratication. One exception was the region in which a country was located. Southeast Asia and the Western Pacic ratied the FCTC earlier than did countries in the Americas and Africa. Participation in the INB was not associated with early ratication of the FCTC nor was an increase in

the number of delegates sent by a country. Being part of the negotiation process did not accelerate ratication once the FCTC was completed. Besides income level, network membership as measured by both NGO participation in the Framework Convention Alliance and increasing membership in GLOBALinkwas the only signicant predictor of early ratication. Increasing membership in GLOBALink, a network in which information and experiences related to the FCTC ratication were shared, was also associated with ratication once the diffusion process got under way. The graphic comparison of network interactions presented in Figures 2 and 3 clearly illustrates the difference between countries that ratied early and those that ratied late in regard to

membership in GLOBALink. The core of the network among nonratifying countries consists of the United States, Switzerland, Argentina, and Indonesia, all of whom may have reasons other than lack of awareness or information about the treaty for postponing ratication of the FCTC. Generally speaking, most countries that have not ratied are outside the ow of information and inuence (as characterized by GLOBALink membership) that may otherwise enable them to ratify the FCTC. This is an interesting nding because it points to the critical role that international information sharing may have on domestic policy processes and suggests that investment in such networks may provide a cost-effective method for supporting the spread of international public health norms in other areas.

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Limitations
Our study had several potential weaknesses. Social, political, and cultural characteristics of states are not easy to quantify and there are always challenges in selecting appropriate variables. There is always the possibility that other, and perhaps better, variables could have been used to represent the determinants of ratication. For a number of countries, information on the variables selected was unavailable, including a lack of GLOBALink data after 2006. The analysis also ignored the strength of tobacco control legislation in countries and whether it changed during the period. The goal of this analysis, however, was simply to provide greater information to identify possible determinants of FCTC diffusion. Future work is needed to improve on the empirical model and to strengthen its explanatory power. The role of system modeling in global tobacco control must also be weighed, as is the case with all large-scale systems modeling efforts, against qualitative information available about the process globally and within specic countries.19 Historical context and political realities within countries cannot adequately be captured in such a macrostudy. In future studies, contextual information could be used to a greater extent to add depth and balance to the analysis; this would provide a more complete picture of the role that the FCTC process and international tobacco control networks have had in diffusing international tobacco control norms to domestic policy.

The initiation of the FCTC process marked the rst time that the WHO member states enacted the organizations power under article 19 of its constitution to negotiate and sign a binding treaty aimed at protecting and promoting public health. It also represented the rst time that the member states cooperated worldwide in a collective response to prevent chronic disease. Considerable time and effort have been invested in the negotiation, ratication, and domestic implementation of the FCTC. The evidence presented here suggests that the speed of FCTC ratication was dependent on forums in which invested individuals within past and potential ratifying countries could exchange information, learn about experiences, and gain reassurance about the consequences of action. Future public health programs should thus be accompanied by a plan for creating opportunities for this interaction; otherwise, diffusion of internationally promoted programs and policies will be delayed and the return on investments diminished. j

2003. Health, Nutrition and Population (HNP) Discussion Paper. Economics of Tobacco Control paper no. 6. 2. World Health Organization. World Health Report Reducing Risks, Promoting Healthy Life. Geneva, Switzerland: World Health Organization; 2002. 3. GLOBALink Tobacco Control, The International Tobacco Control Community. Available at: http:// www.globalink.org. Accessed March 24, 2010. 4. WHO Framework Convention on Tobacco Control. Geneva, Switzerland: World Health Organization; 2003. 5. Rogers EM. Diffusion of Innovations. 5th ed. New York, NY: The Free Press; 2003. 6. Valente TW. Network Models of the Diffusion of Innovations. Cresskill, NJ: Hampton Press; 1995. 7. Valente TW. Models and methods for innovation diffusion. In: Carrington PJ, Scott J, Wasserman S, eds. Models and Methods in Social Network Analysis. Cambridge, United Kingdom: Cambridge University Press; 2005. 8. World Health Organization. Tobacco Free Initiative Web site. Available at: http://www.who.int/tobacco. Accessed April 22, 2010. 9. WHO Report on the Global Tobacco Epidemic, 2008: the MPOWER package. Geneva: World Health Organization; 2008. 10. Freedom in the World 2009. Washington, DC: Freedom House Inc; 2009. 11. Food and Agricultural Organization. Tobacco Leaf Production. Available at http://faostat.fao.org. Accessed February 2009. 12. Shafey O, Eriksen M, Ross H, Mackay J. The Tobacco Atlas. Atlanta, GA: American Cancer Society, World Lung Foundation; 2009. Available at: http://www. tobaccoatlas.org. Accessed April 22, 2010. 13. World Health Organization. Framework Convention on Tobacco Control Web site. Available at: http:// www.who.int/gb/fctc. Accessed April 22, 2010. 14. Breiger RL. Duality of persons and groups. Soc Forces. 1974;53(2):181190. 15. Borgatti SP, Everett MG. Network analysis of 2-mode data. Soc Networks. 1997;19(3):243269. 16. Wasserman S, Faust K. Social Networks Analysis: Methods and Applications. Cambridge, United Kingdom: Cambridge University Press; 1994. 17. Zeger SL, Liang KY. Longitudinal data analysis for discrete and continuous outcomes. Biometrics. 1986; 42(1):121130. 18. Borgatti SP. Netdraw. Lexington, KY: Analytic Technologies; 2005. 19. National Cancer Institute. Greater Than the Sum: Systems Thinking in Tobacco Control. Tobacco Control Monograph no. 18. Bethesda, MD: US Dept of Health and Human Services, National Institutes of Health, National Cancer Institute; 2007. NIH publication no. 06-6085. 20. Valente TW, Rogers EM. The origins and development of the diffusion of innovations paradigm as an example of scientic growth. Sci Commun. 1995;16(3): 242273.

About the Authors

All authors are with the Department of Preventive Medicine, University of Southern California, Los Angeles. Heather L. Wipi is also with the Institute for Global Health, University of Southern California, Los Angeles. Kayo Fujimoto and Thomas W. Valente are also with the Institute for Health Promotion and Disease Prevention Research, University of Southern California, Los Angeles. Correspondence should be sent to Heather L. Wipi, PhD, Department of Preventive Medicine, Keck School of Medicine, USC Institute for Global Health, University of Southern California, 1441 Eastlake Avenue, Room 4425A, Los Angeles, CA 90033 (e-mail: hwipi@usc. edu). Reprints can be ordered at http://www.ajph.org by clicking the Reprints/Eprints link. This article was accepted July 5, 2009.

Conclusions
This study has implications for the future study of the diffusion of innovations and public health. Historically, it has been prohibitively challenging to conduct large-scale studies in which social network and time of innovation adoption data are available. Generally, this is because the time span for diffusion is long and data collection at multiple time points becomes prohibitively expensive.5,20 The public availability of the FCTC documentation and ratication dates, global databases, including the WHO Report on the Global Tobacco Epidemic9 and the Tobacco Atlas,12 and the existence of tobacco control networks, including GLOBALink and the Framework Convention Alliance, provide an incredibly rich source of data for this and future diffusion studies.

Contributors
H. L. Wipi originated the study and assembled the data. K. Fujimoto conducted network computations and analyses. T. W. Valente originated the study and the analysis plan. All authors interpreted ndings and contributed to the writing of the article.

Acknowledgments
Support for this study was provided through an Advancing Scholarship in the Humanities and Social Sciences grant to H.L. Wipi from the University of Southern California.

Human Participant Protection

No protocol approval was necessary because data were obtained from secondary sources.

References
1. Guindon GE, Boisclair D. Past, Current and Future Trends in Tobacco Use. Washington, DC: World Bank;

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