“Quitting like a Turk:” How political priority developed for tobacco control in Turkey Connie Hoe a, * , Daniela C. Rodriguez a , Yes ¸ im Üzümcüo  glu b , Adnan A. Hyder a a Johns Hopkins University Bloomberg School of Public Health, Department of International Health, Baltimore, MD, USA b Middle East Technical University, Department of Psychology, Ankara, Turkey article info Article history: Received 23 October 2015 Received in revised form 3 May 2016 Accepted 22 July 2016 Available online 25 July 2016 Keywords: Turkey Tobacco control Political priority Agenda-setting Health policy Foreign policy abstract In recent years, tobacco control emerged as a political priority in Turkey and today the country is widely regarded as one of the global leaders in tackling tobacco use. Although political priority is considered a facilitating factor to the success of addressing public health issues, there is a paucity of research to help us understand how it is developed in middle-income countries. The primary aim of this study is to understand the process and determinants of how tobacco control became a political priority in Turkey using the Multiple Streams Framework. A mixed-methods case study approach was used whereby data were gathered from three different sources: in-depth interviews (N ¼ 19), document reviews (N ¼ 216), and online self-administered surveys (N ¼ 61). Qualitative data were collected for the purpose of un- derstanding the processes and determinants that led to political prioritization of tobacco control and were analyzed using deductive and inductive coding. Quantitative data were collected to examine the actors and were analyzed using descriptive statistics and network nominations. Data were triangulated. Findings revealed that tobacco control achieved political priority in Turkey as a result of the development and convergence of multiple streams, including a fourth, separate global stream. Findings also shed light on the importance of Turkey's foreign policy in the transformation of the political stream. The country's desire for European Union accession and global visibility helped generate a political environment that was receptive to global norms for tobacco control. A diverse but cohesive network of actors joined forces with global allies to capitalize on this opportunity. Results suggest (1) the importance of global-agenda setting activities on political priority development, (2) the utility of aligning public health and foreign policy goals and (3) the need to build a strong global incentive structure to help entice governments to take action on public health issues. © 2016 Elsevier Ltd. All rights reserved. 1. Introduction Tobacco use is a grave public health concern in Turkey, causing an estimated 100,000 deaths per year (Bilir et al., 2009). The severity of this issue is illustrated by the phrase “smoke like a Turk,” which is used in Europe to describe a person who smokes exces- sively (Butler, 2009). In recent years, Turkey has emerged as a global leader in tobacco control challenging this popular percep- tion. In 2008, it became the third country in Europe to introduce a comprehensive smoke-free ban, and in 2013 it succeeded in being the only country in the world to have implemented all WHO MPOWER (M onitor, P rotect, O ffer help, W arn, E nforce and R aise taxes) measures, which were developed to help countries imple- ment tobacco control interventions (Bilir and € Ozcebe, 2012; WHO, 2013). Between 2006 and 2013, smoking prevalence also decreased from 33.8% to 27.1% (Ünüvar et al., 2006; MoH, 2013). These ac- complishments are highly significant to Turkey given the perceived importance of tobacco to the country. Political priority pertains to the agenda setting phase of the policy process (Shiffman and Ved, 2007). Although prioritization does not guarantee successful implementation, it is considered a facilitating factor to the success of addressing public health issues (Catford, 2006; Shiffman, 2007). Political priority has been oper- ationalized by Shiffman (2007) and Fox et al. (2011) as: “(1) Expressed commitment or verbal declarations of support for an issue by high level, influential political leaders; (2) Institu- tional commitment or specific policies and organizational infra- structure in support of an issue; and (3) Budgetary commitment * Corresponding author. 615 N. Wolfe Street, Suite E-8638, Baltimore, MD 21205, USA. E-mail address: choe1@jhu.edu (C. Hoe). Contents lists available at ScienceDirect Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed http://dx.doi.org/10.1016/j.socscimed.2016.07.027 0277-9536/© 2016 Elsevier Ltd. All rights reserved. Social Science & Medicine 165 (2016) 36e45