Excluding bottled water, only 1.3% of food and beverage advertising across the Sydney train network is consistent with a healthy diet

New research from the Boden Institute of Obesity, Nutrition, Exercise & Eating Disorders at the University of Sydney, and Sydney Law School, has investigated the quality of nutrition of food and beverage advertising on every station of Sydney’s metropolitan train network.

Judged by revenues, outdoor advertising of food, on billboards and other advertising spaces, is on the rise.

Sydney Trains generated over $12 million in advertising revenue in the 2013-14 financial year, and this was expected to increase to at least $100 million over the subsequent 5 years.

A research team, led by Emma Sainsbury, collected data in February (summer) and July (winter) of 2016, photographing a total of 6931 advertisements across the 178 stations in the network.

Each advertisement was coded as core (a healthy food or beverage recommended for daily consumption), or discretionary (high fat, sugar and/or salty food not recommended for daily consumption), based on the Australian Guide to Healthy Eating.

The results tell you what you probably already know: Sydney train stations are a great place to advertise junk food and beverages.

Just over a quarter of total advertisements (1915/6931, or 27.6%) promoted food and beverages.

Of the food and beverage advertisements, 84.3% were for discretionary foods/beverages, 8% were for core foods/beverages, and the remainder (7.6%) were miscellaneous advertisements, mostly brand-only advertisements that did not mention specific products.

Significantly, the core foods/beverages category consisted mostly of bottled water vending machines (74.4%), and billboard advertisements for bottled water (11%).  When advertisements for bottled water were excluded, only 1.3% of food and beverage advertising on the Sydney train network was for core foods.

The most commonly advertised discretionary products were potato chips (25%), sugar-sweetened beverages (23%, mostly flavoured milks and soft drinks), and intense or artificially-sweetened beverages (18.7%).

Despite food advertisements comprising just over a quarter of all advertisements, Coca-Cola and PepsiCo (which includes PepsiCo beverages and The Smith’s Snackfood Company) were the largest advertisers overall, contributing 10.9% and 6.5% of total advertising across the network.

Advertisements for alcohol made up over 6% of food and beverage advertising, and about 2% of total advertising.

There is obviously a total disconnect between foods and beverages advertised on Sydney trains and the kinds of foods and drinks that make up a healthy diet.

What do advertisers have against healthy food and beverages, I wonder?

A large number of self-regulatory initiatives ostensibly regulate food and beverage advertising in Australia.

However, these have failed to achieve a healthy food advertising environment, probably by design.

The results of this study support the case for government to pressure industry to shift the mix of food and beverage advertising towards products that are more consistent with a healthy diet.

The paper reviews some of the regulatory approaches that might be used, from outright bans, to interim and longer-term targets for reductions in the overall volume of unhealthy food advertising, based on a credible nutrient profiling system that evaluates the quality of nutrition of the product.

Restrictions on the volume of particular kinds of advertising, as a percentage of total advertising, do exist in other jurisdictions.

In Ireland, for example, the General Commercial Communications Code limits the volume of television advertising of foods high in fat, salt or sugar, to a maximum of 25% of sold advertising time across the broadcast day (para 16.10).

However, much of the impetus for constraints on unhealthy food advertising arises from the belief that children are particularly vulnerable and deserve to be protected.  Unlike, say, television programs that are made specifically for children, the train network is used by substantial numbers of both adults and children.

Another approach could be to significantly increase the proportion of train station advertising allocated to the promotion of healthy, core foods and beverages, perhaps through higher pricing strategies for advertising of junk foods and sugary drinks.

The food, beverage and advertising industries ought to be taking the lead here, but how likely is that?!

The prevailing ideology, shared by the food and beverage industries, their allies and lobbies, is that you get the health you deserve.

If you can beat temptation and eat a healthy diet, you deserve to be healthy.

But if you eat a poor diet, if you routinely consume the diet that is overwhelmingly advertised, then you get what’s coming to you.

That’s personal responsibility.

It’s great for business (there’s great margins on nutritionally poor foods), but not great for the health budget, nor for individuals and families.

Maybe that’s why the food and beverage industry needs round-the-clock lobbyists in Canberra to explain to politicians and the rest of us how the world works.

Because otherwise someone might start asking crazy questions…like…Why shouldn’t the mix of advertising across the Sydney train netework be better aligned with a healthy diet?

The paper can be downloaded free of charge here.

Queensland’s Healthy Futures Commission

Health promotion in Queensland could receive a turbo-boost if the Healthy Futures Commission Queensland Bill 2017 is passed.

This Bill illustrates a sometimes neglected aspect of public health law: use of law to build new institutions, to encourage partnerships, and to create a clear legislative mandate to address health challenges.

The Healthy Futures Commission was an election commitment by the Palaszczuk Labor Government.

It is intended to help achieve two measures of success set out in Queensland Health’s 10 year vision and strategy.  These are to:

  • Reduce childhood obesity by 10%; and
  • Increase levels of physical activity by 20% (p 15/28).

The Bill would establish the Healthy Futures Commission Queensland, a portfolio agency within the Health Ministry.

Its purpose is to “support the capacity of children and families to adopt a healthy lifestyle”, and contribute to the reduction of health inequalities for children and families (s 3).

The functions of the Committee include: advocating for the social conditions and environments necessary to support healthier lifestyles and reduce health inequalities, and developing partnerships (s 9).

The Commission has power to make grants on matters relating to its functions, to industry or community organisations, universities, local governments, and business entities.  The source of funding for these grants would be the Healthy Futures Queensland fund established by the Bill (s 41), which is also the funding source for the Commission’s own costs and expenses.

Queensland’s Minister for Health and Ambulance Services, Cameron Dick, has stated the Commission will have a budget of $20 million over three years.

The Bill requires that at least 55% of total funding shall be paid out as grants (s 41(4)).  This reflects the importance of the Commission’s grants function, and appears to be intended to ensure that the majority of funds are expended on “real world” interventions and projects addressing healthier eating and physical activity.  This funding requirement also creates a natural check on the size of the Commission itself.

The Commission must prepare an annual project funding plan each year for approval by the Board and the Minister (s 42).

In performing its functions, the Commission is required to take into account the social determinants of health, as understood in the Rio Political Declaration on Social Determinants of Health, as well as the needs of vulnerable groups experiencing health inequity including Aboriginal and Torres Strait Islander communities.

The Commission is not entirely independent of politics and must comply with any direction given by the Health Minister about the performance of the Commission’s functions (s 10).  The Minister may request reports from the Commission on relevant matters but may not give directions about the content of any such report (s 11).

Queensland LNP Senator Barry O’Sullivan has called for the Qld Health Minister to instruct the Commission never to recommend a sugar tax.

According to Senator O’Sullivan, the Commission “should focus on promoting personal responsibility to reduce obesity.”

Readers of this blog will already have picked up on the message that the National Party doesn’t like sugary drinks taxes.

However, outside of Australia, as a recent paper by Sarah Roach and Lawrence Gostin points out, sugary drinks taxes are gaining momentum, encouraging reductions in consumption of sugary drinks, raising revenues for government, educating consumers and at least in the UK, driving reformulation.

Queensland’s Healthy Futures Commission would be governed by a 6-member Board appointed by the Governor in Council on the recommendation of the Minister.  Board members must have qualifications or experience in business, law, leading partnerships, or assessing the impact of social conditions on health equity.  Board members are appointed to 4 year terms (and may be re-appointed) (s 16).

The Board is empowered to establish committees, whose membership could include appropriate external experts, to assist it to perform its functions (s 29).

Once more with feeling…Barnaby Joyce on the merits of a sugary drinks tax

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Photo: Tongan Health Promotion Foundation

 

When I looked up from marking exams and saw the look on Barnaby Joyce’s face, I just knew he was seeing red about the Grattan Institute’s proposal for a sugary drinks tax, levied at a rate of 40 cents per 100 grams of sugar.

The Grattan Institute report estimates that such a tax would reduce the consumption of sugary drinks by about 15% and generate up to half a billion dollars that could help to pay for a broad array of obesity-related programs.

Imagine!  A public health policy that fights obesity, diabetes and tooth decay AND generates revenue.

The National Party hate the idea.  Deputy Prime Minister and Leader of the Nationals, Barnaby Joyce told reporters:

“If you want to deal with being overweight, here’s a rough suggestion: stop eating so much, and do a bit of exercise.  There’s two bits of handy advice and you get that for free.  The National Party will not be supporting a sugar tax”.

Well that’s what he said.

But here’s what I heard: “We know that obesity and diabetes are out of control.  But we have ideological objections to being part of the solution”.

The same day that Minister Joyce shared these thoughts with reporters, the Australian Food and Grocery Council issued a press release saying that it was seeking a “constructive response to obesity”.

“Obesity is a serious and complex public health issue with no single cause or quick-fix solution”, explained the AFGC, but “it is not beneficial to blame or tax a single component of the diet”.

With most complex issues, you start somewhere.  You come up with evidence-informed policies and you try them out.  You rigorously evaluate their performance, and learn by doing.

But not with obesity.  “Complexity” is the new enemy of action.  Since the causes of obesity are complex, every “single” policy advanced in response can be dismissed as a dangerously simplistic solution to a complex problem.

Welcome to obesity, the problem we’re not allowed to start to fix.

Except with personal responsibility, of course.

 

Personal responsibility…the answer to obesity, traffic accidents, terrorism, Zika virus, perhaps everything?

In a limited sense, Barnaby Joyce is right.

The only cure for personal obesity is personal responsibility.

But personal responsibility has turned out to be a spectacularly poor solution to “societal obesity”.

By societal obesity, I am referring to the trend towards overweight and obesity that has arisen over the past few decades and now affects the majority of adult men and women (and more than one in four children).

Since each of us is an individual, and because we live in a culture that prizes individual autonomy, it’s easy to fall into the trap of believing that individual effort, personal motivation, is the solution to the world’s ills.

But just as the global epidemics of obesity and diabetes were not caused by a catastrophic, global melt-down in personal responsibility, personal responsibility is equally unlikely to provide the magic solution.

That’s where public policies come in.

Governments know all this, but with the exception of tobacco control, they seem reluctant to apply their knowledge in the area of preventive health.

The fact is, from road traffic accidents to terrorism, smart governments:

  • acknowledge the complexity of the factors that contribute to societal problems;
  • They acknowledge that multiple interventions are needed, in many settings;
  • They acknowledge that possible solutions need to be trialled now, under conditions of uncertainty, instead of handing the problem to future generations.
  • They monitor the actions they take, because healthy public policy is a dynamic, ongoing process; and finally
  • They give a damn.  Meaning that they recognise they are accountable to the community for helping to solve difficult, societal problems, and for the performance of the public policies they administer.

Imagine if Australia’s government took that approach with obesity.

 

The debate about a sugary drinks tax is here to stay: it will never go away

A tax on sugary drinks will get National Party politicians in trouble with sugar producers, and Liberal Party politicians in trouble with big food.

The real problem is that it might work.  Based on the experience of Mexico, a sugary drinks tax will very likely cause consumers to purchase fewer sugary drinks.

Despite batting it away, a tax on sugary drinks is on the public agenda, and it’s here to stay.  I don’t see the sugary drinks industry winning on this issue indefinitely.

Partly because Australian health researchers will keep it on the agenda.

It will come back, and back.  Especially as evidence of its success accumulates overseas.

One conversation worth having is how revenues from a sugary drinks tax might support agricultural producers in rural Australia, helping to cushion them from the adverse effects (if any) of the tax and creating incentives for the production of a sustainable and healthy food supply.

That is simply one question worth considering during the process of developing a national nutrition policy (which we don’t currently have).

In the meantime, Australian health advocates need to broaden their base.

Advocacy for public policy action on obesity needs to become more closely integrated with advocacy on food security.   And advocacy in both areas needs to be linked more closely to action on reducing health inequalities.

But enough about all that.  You really came here for Barnaby, didn’t you?

OK, here he is:

The ATO is not a better solution than jumping in the pool and going for a swim. The ATO is not a better solution than reducing your portion size. So get yourself a robust chair and a heavy table and, halfway through the meal, put both hands on the table and just push back. That will help you lose weight.”

Sydney Health Law’s Food Governance Conference

 

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In the first week of November, Sydney Health Law will be hosting the Food Governance Conference. The conference is a collaborative endeavor between Sydney Law School and the Charles Perkins Centre, the University of Sydney’s dedicated institute for easing the global burden of obesity, diabetes, and cardiovascular disease. The conference also has sponsorship from The George Institute for Global Health and the University’s Cancer Research Network.

The Food Governance Conference will explore the role of law, regulation and policy in addressing the key challenges associated with food and nutrition in the 21st century, including food security, food safety, and preventing diet-related disease such as diabetes and cardiovascular disease. It also engages with issues related to sustainability, equity, and justice in the food supply, with a strong focus on nutrition and diet-related health in Aboriginal and Torres Strait Islander communities.

In taking such a broad focus we hope that the Conference will highlight the interrelationships between the main challenges facing the global food system in the 21st century. The conference will also showcase the work of researchers in developing new, innovative solutions to these challenges, with the conference including presenters from across Australia, as well as from the UK, Canada, and New Zealand. Some of the issues considered at the conference include:

  • Taxes on sugar-sweetened beverages
  • Free range egg labeling
  • Urban farming
  • The role of business in improving nutrition and diet-related health, and
  • The influence of trade agreements on the global food system

A draft conference program and registration form are available on the conference website.

Public events

We have an exciting program of events around the Food Governance Conference, including two free, public lectures to open the conference.

Professor Corinna Hawkes will be giving the opening address for the conference on Tuesday the 1st of November at 6pm at the Charles Perkins Centre Auditorium. This lecture is free and open to the public. Professor Hawkes is the Director of the Centre for Food Policy at City University London and a world-renowned expert on food and nutrition policy. She’ll be speaking on the three biggest challenges facing the food system, and how we fix them. If you’re interested in this talk, you can register at this link.

Dr Alessandro Demaio will also be giving a public lecture at 1-2pm on Tuesday the 1st of November at Sydney Law School. Dr Demaio (from the World Health Organisation) will be speaking on the links between food, nutrition and cancer, and what the nutrition community can learn from the cancer community from its fight against tobacco. Further details about his talk are available at this link.

Workshop on food advocacy

Along with the Charles Perkins Centre, the Australian Right to Food Coalition is hosting a masterclass on becoming an effective food policy advocate, featuring Professor Corinna Hawkes. The purpose of this master class is to encourage debate among academics and civil society about the role of advocacy in food and nutrition policy, what it is, and how it can be used more effectively. Registrations for the master class can be made herePlease note that the master class is now full.

We’re looking forward to the inaugural Food Governance Conference at the University of Sydney, and we hope to see you there. We welcome any questions about the conference, which can be directed to Dr Belinda Reeve: Belinda.reeve@sydney.edu.au

Follow #foodgovernance2016 on Twitter for updates about the conference!

WHO Commission on Ending Childhood Obesity presents final report and recommendations

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The World Health Organisation’s Commission on Ending Childhood Obesity, appointed by WHO Director-General Dr Margaret Chan in 2014, has now formally presented its final report.

The Commission was co-chaired by Sir Peter Gluckman, the Chief Science Advisor to the Prime Minister of New Zealand, and Dr Sania Nishtar, the founder and President of Heartfile, a health policy think tank based in Pakistan.

The Commission held hearings in all 6 WHO regions, and was supported by two technical working groups: the Ad Hoc WG on Science and Evidence, and the Ad Hoc WG on Implementation, Monitoring and Accountability.

In 2014, an estimated 41 million children under 5 years of age were either overweight or obese (this is defined as the proportion of children whose weight for height scores are more than 2 standard deviations, or more than 3 standard deviations, respectively, from the WHO growth standard median).

The Commission’s strategic approach rests on three categories of interventions:

  • interventions to tackle the obesogenic environment in order to improve the healthy eating and physical activity behaviours of children;
  • interventions targeting critical stages of the lifecourse; ie (i) preconception and pregnancy; (ii) infancy and early childhood; and (iii) older childhood and adolescence;
  • interventions to treat obese children in order to improve their current and future health.

A number of the Commission’s recommendations addressing the obesogenic environment, and critical stages of the lifecourse, in particular, confirm the role for law and regulation in improving the food and physical activity environment for children.

In a move sure to thrill the fizzy drinks industry, the Commission has called on countries to implement an effective tax on sugar-sweetened beverages, and noted that some countries may also consider a tax on foods high in fats or sugar.

Noting “unequivocal evidence that the marketing of unhealthy foods and sugar-sweetened beverages is related to childhood obesity”, the Commission has called on countries to implement the WHO’s Set of Recommendations on the Marketing of Foods and Non-alcoholic Beverages to Children.   It has also called for cooperation between Member States of the World Health Assembly to reduce the impact of cross-border marketing of unhealthy foods and beverages.

The Commission has called for a standardised global nutrient labelling system, as well as the implementation of interpretive front-of-pack nutritional labelling supported by public education to improve nutritional literacy.  Interpretive food labelling has consistently been a highly contested area of food law and policy.  For example, the European Food Industry reportedly spent 1 billion euro to ensure that front-of-pack traffic light labeling did not become a Europe-wide standard.  Traffic light labels interpret the quality of the nutrition of food by means of highly visible red, amber and green symbols that correspond to the amount of saturated fat, salt and added sugar in the product.

The Commission’s recommendation that schools, child-care settings and children’s sports facilities should be required to create healthy food environments may also require legislation or regulations for successful implementation in some countries.  The Commission has also specifically recommended that countries eliminate the sale or provision of unhealthy foods, such as sugar-sweetened beverages and energy-dense, nutrient-poor foods, in schools.

In the United States, the federal government subsidises the provision of breakfasts and lunches served at school to children from low-income families.  This has enabled the US Department of Agriculture to issue regulations  requiring schools that participate in the national school lunch and breakfast program to improve the nutritional quality of the foods that are served.   However, these standards have faced relentless opposition from the junk food industry and from Congress.  Mandatory standards to improve the nutritional quality of school food have been introduced in a number of jurisdictions, including England and Scotland.

Other recommendations that may require legislative or executive action include the enforcement of the International Code of Marketing of Breast-milk Substitutes and subsequent resolutions of the World Health Assembly (WHA).

The Commission’s report will be presented to the members of the WHA in May 2016, where further actions may be taken to support the implementation of the Commission’s recommendations.

Those with an interest in obesity should also keep an eye out for the report of the Lancet Commission on Obesity, co-chaired by Professor Boyd Swinburn (University of Auckland), and Professor Bill Dietz (George Washington University).  In this paper, Professors Swinburn and Dietz outline the work of their Commission.

 

 

The role of law in noncommunicable disease prevention: an easy-to-digest explanation

Public health lawyers like me are often challenged on their claim that the law can (and should) play a significant role in the prevention of noncommunicable diseases (NCDs). Future Leaders, an Australian philanthropic organisation, has recently published an open-access, clearly written book on NCD prevention called Dancing in the Rain: Living with NCDs, which includes a chapter by Professor Larry Gostin and I on the role of law in NCD prevention. Here we describe the growing global governance framework for NCD prevention, and the range of new initiatives that governments around the world are using to combat NCDs, including measures that draw upon law and regulation. We contrast this widespread global innovation with Australia’s failure to take decisive action in relation to the prevention of obesity and excessive alcohol consumption, asking why Australia has ended up as a ‘laggard’ in these areas when it remains the world leader in tobacco control. This is an easy-to-digest introduction to the interaction between law and NCD prevention, and it sits alongside a number of other insightful chapters from prominent Australian activists and academics, including Dr Alessandro Demaio, Professor Fiona Stanley, and Professor Rob Moodie.

Dancing in the Rain is accessible in full via the following link: http://bit.ly/1QoDyLS

Dancing on Christopher Hitchens’ grave? The tricky business of talking about consequences

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Vanity Fair, February 2004

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A “pro-smoking blogger for the libertarian right”  accuses me of “dancing on Christopher Hitchens’ grave”.

And other stuff.

Christopher Snowdon is a Research Fellow for the UK-based Institute of Economic Affairs, a think tank that receives tobacco funding.  He is an opponent of plain tobacco packaging, keeper of the pure flame of libertarianism etc.

My sin – contained in a paper forming part of a symposium on public health regulation and the “nanny state”, was to reflect on a self-confessed “crime spree” Hitchens took in New York City  in late 2003.

During the course of an autumn day, Hitchens broke as many of the city’s “petty ordinances” as he could, particularly its smoke-free laws.

At the time, Michael Bloomberg was in the second year of his first, 4-year term as NYC Mayor.  He went on to serve 3 full terms, introducing tobacco control laws that saw the adult smoking rate fall by 28% between 2002 and 2012, and the youth smoking rate fall by 52% between 2001-2011 .

Which is a terrible result, if you’re a tobacco company, but a magnificent result for New Yorkers – with changed life trajectories and longer, healthier lives for hundreds of thousands of people.

You can read about Michael Bloomberg’s public health legacy here.

Apparently embittered at the constraints on his smoking, Hitch lashed out, reflecting on the “shriveled core of the tiny Bloombergian mind”, and ending with:

“Who knows what goes on in the tiny, constipated chambers of his mind? All we know for certain is that one of the world’s most broad-minded and open cities is now in the hands of a picknose control freak.”

The editor of Vanity Fair, Graydon Carter, who at the time was being serially fined by the NYC Health Department for flouting its smoke-free laws and smoking in his office, published the whole account.

Then, in June 2010, at the height of his powers, Hitchens announced he had cancer  of the oesophagus.  As one journalist wrote, “The celebrated drinker and smoker who once claimed that “booze and fags are happiness” had succumbed to a cancer most often associated with drinking and smoking.”

Hitchens died less than 18 months later.

Like his hero Hitchens, Snowdon believes that smoke-free laws are anti-libertarian.  The mind boggles at this point, given that globally, one in ten people who die from tobacco are non-smokers who are unintentionally harmed (poisoned) by smokers….

However, to my mind the more interesting theme that excites Snowdon is the question of whether Hitchens’ diagnosis challenged his libertarian convictions.  Snowdon assumes that the rationale for discussing this issue was to concoct some sort of contrived, deathbed confession:

“Magnusson clearly thinks that Hitchens got his comeuppance when he died of cancer and wants to believe that he renounced his principles on his death bed.”

The record shows that Christopher Hitchens castigated those who promoted effective tobacco control, yet spoke frankly and publicly about his own cancer, acknowledging that it was probably caused by his smoking and drinking.

Hitchens made his choices, and talked about them freely.  He made his private life a public matter.

So we have permission, I think, to talk about Hitchens – who I suspect would have approved of being the topic of conversation.

“I’ve come by this particular tumor honestly”, he told Anderson Cooper on CNN in August 2010.  “If you smoke, which I did for many years very heavily with occasional interruption, and if you use alcohol, you make yourself a candidate for it in your sixties.” “I might as well say to anyone who might be watching – if you can hold it down on the smokes and the cocktails you may be well advised to do so”.

Cooper responded “That’s probably the subtlest anti-smoking message I’ve ever heard”.

“The other ones tend to be more strident”, Hitchens replied, “and for that reason, easy to ignore”.

“Even if this weren’t incredibly tasteless” Snowdon writes, “Magnusson could hardly have found a less fitting person to use as an example.”

Snowdon seems to think that the point of discussing Hitchens is to trip him up on his words, seek to make an object lesson out of him, or worse, to gloat.

But there are other reasons why Hitchens’ account of his illness is worth reflecting on.

Certainly, it was a compelling story. Statistics are easy to brush off: just ask a smoker.  But stories are a little harder.

Here comes this libertarian prophet – as sure as any libertarian ever was about the infantilising effect of public health laws – suddenly forced to come face to face with his own premature (and probably preventable) death.  Did he have conflicting feelings, second thoughts?  It’s not an unfair question.

“In whatever kind of a ‘race’ life may be”, Hitchens wrote  in 2010, “I have very abruptly become a finalist….In one way, I suppose, I have been ‘in denial’ for some time, knowingly burning the candle at both ends … .[F]or precisely that reason, I can’t see myself smiting my brow with shock or hear myself whining about how it’s all so unfair … . Instead, I am badly oppressed by a gnawing sense of waste. I had real plans for my next decade and felt I’d worked hard enough to earn it. Will I really not live to see my children married?  To watch the World Trade Center rise again?

Through his story, we catch a glimpse of the public interest that public health laws and policies are intended to protect.

The public interest in tobacco and alcohol control laws does not exist for the sake of some abstracted, disembodied “public”, but ultimately for the sake of all those individuals who might otherwise die prematurely, or just as frequently, as Simon Chapman writes, live long in distress and isolation due to the disintegrating impacts of their illness.

Bloomberg’s tobacco control laws were intended to help prevent the kind of death Hitchens died.  To say that is not to gloat.

Consequences tend to be trivialised or absent when libertarians set out their plans for how the world ought to be.

The narrative we tend to get is the one written by the be-suited Hitchens in 2003, flying through Central Park with his feet off the bicycle pedals, witty, cancer-free, not the man 7 years later, who writes  “The chest hair that was once the toast of two continents hasn’t yet wilted, but so much of it was shaved off for various hospital incisions that it’s a rather patchy affair. I feel upsettingly de-natured. If Penélope Cruz were one of my nurses, I wouldn’t even notice”.

How should public health advocates talk about consequences?

In the United States, gun enthusiasts have become so highly proficient at ignoring consequences that anyone who dares link the most recent gun-related massacre [insert dates & details] with that shocking, leftist, evil thing called “gun control” – is howled down for seeking to “politicise a personal tragedy“.

Plenty of compelling stories, it seems, but never a teachable moment.

But for the rest of us, prevention matters because people matter.  Their needless suffering or death is relevant to how we evaluate the wisdom of government actions, laws and policies.

The nanny state conspiracy theorists overstate their case.  Hitchens’ freedom to make choices about smoking, drinking, diet and lifestyle were his for the taking.  No one stood in his way.

Hitchens had no Damascus conversion over tobacco, or anything else for that matter, but his public expressions of regret were no less powerful for their subtlety.

[Interview between Anderson Cooper (CNN) and Christopher Hitchens, 6 August 2010: http://www.democraticunderground.com/discuss/duboard.php?az=view_all&address=385×492527 (transcript);  http://ac360.blogs.cnn.com/2010/08/07/video-extended-interview-hitchens-on-cancer-and-atheism/ (video).]

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