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Background: In many low-and middle-income countries, tobacco smoking andharmful alcohol consumption are major public health threats that are inadequatelyaddressed at the policy level. For example, efforts to formulate a comprehensivetobacco control policy have been on going in Zambia for close to 12 years, but thecountry has still not yet been able to finalise one. While Zambia adopted an alcoholpolicy in 2018, its implementation remains a huge challenge. This thesis sought toenhance understanding of the context and the collaborative dynamics in the Zambiatobacco control and alcohol policy processes. In particular, it aimed (i) to determinethe extent and sociodemographic determinants of tobacco smoking and harmfulalcohol consumption (Sub-study 1); (ii) to explore and explain the role of principledengagement and shared motivation in the delayed tobacco control policy (Sub-study2); and (iii) to unpack factors that shaped the capacity for joint action in theimplementation of the alcohol policy (Sub-study 3).

Methods: This was an embedded mixed-methods study that comprised a acrosssectionalstudy based on the Word Health Organization STEPs population-basedsurvey of 4302 individuals (Sub-study 1) and two policy case studies – the tobaccocontrol policy development (Sub-study 2) and the alcohol policy implementation(Sub-study 3). Sub-study 2 used key informant interviews data collected from 27tobacco control policy stakeholders across several government sectors, civil society,and an international organisation. The data was supplemented with a documentreview of tobacco laws and policies in Zambia. Regarding Sub-study 3, 25 keyinformant interviews were conducted with members of the National Alcohol PolicyImplementation Coordination Committee. The quantitative data were analysedusing log binomial regression while thematic analysis was applied to the interviewdata.

Results: For the context, Sub-study 1 showed substantial disparities in daily tobaccosmoking and binge drinking between men and women. There was a higherprevalence of smoking in men, older adults, and those with the lowest educationlevel, while binge drinking was more prevalent in men and urban residents. Substudies2 and 3 revealed several system level factors that affected the collaborationin the tobacco control policy process, including interference from the tobaccoindustry, contradictory laws that incentivise tobacco production and weakenforcement of subsidiary tobacco control laws. Further, the systemic issuesaffecting collaboration in implementation of the alcohol policy comprised theframing of alcohol as an economic issue, the weak regulation of illicit alcoholvproduction and the sociocultural acceptance of harmful alcohol consumptionbehaviours. According to Sub-study 2, the collaborative dynamics of principledengagement and shared motivation in the tobacco control policy process have beenconstrained by ineffective communication, mistrust, limited evidence, the absenceof community advocacy and the lack of authority among sector representatives. Substudy3 revealed that the alcohol policy is generally recognised as a framework forstakeholder action targeting the control of harmful alcohol consumption. However,weak coordination and resource challenges among implementing agencies haveundermined their capacity for joint action, ultimately impeding the implementationof this policy.

Conclusion: The higher prevalence of tobacco smoking and binge drinking amongsub-groups such as men, older adults, those with the lowest education level andurban residents calls for targeted strategies in collaborative efforts to addresstobacco and alcohol. Several policy and legal issues affect the development of thetobacco control policy, while the collaborative dynamics are fraught with challengesthat threaten critical collaborative outcomes such as trust, commitment andlegitimacy. Thus, embracing practices that seek to foment trust, understanding, andlegitimacy among key government sectors may go a long way in acceleratingcollaboration in the tobacco control policy process. Furthermore, enhancing thecollaborative efforts to implement the alcohol policy will require strengthening thecapacity for joint action by overcoming coordination and resource challenges amongimplementing agencies.