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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The ACT sin bins junk food ads on buses

The ACT has taken steps to ban fast-food ads on buses. Image from abc.net
The ACT has taken steps to ban fast-food ads on buses. Image from abc.net

The ACT attracted media attention this week for becoming the first Australian jurisdiction to regulate ride-sharing services like Uber. But the ACT’s also been active in an area that’s close to the heart of many public health advocates: regulation of junk food and alcohol advertising. Promotions for these products will be banned on ACTION buses, along with ads for gambling, fossil fuels, and weapons, under a strict new government policy.

While derided by critics as another example of the “Nanny State” in action, the move represents a win when it comes to protecting children from junk food promotion. In discussing the ban, the ACT Minister for Territory and Municipal Services acknowledged that “[i]t’s quite clear that junk food advertising is targeted at children, in many many places it’s quite pervasive and… buses are just another example of that… we need to make sure that kids are getting a healthier message given the level of childhood obesity we see in our community.”

There’s little appetite for stronger restrictions on junk food ads at the federal level, despite the National Preventative Health Taskforce recommending legal measures to reduce children’s exposure to junk food ads back in 2008. This was followed by several attempts by The Greens party to introduce legislative amendments that would restrict junk food promotions on television. As with tobacco control, maybe legislative restrictions on junk food marketing to children need to start at the local level and work their way up.

The ACT’s policy also reflects growing government interest in “walking the talk” when it comes to obesity prevention, including by restricting the sale and promotion of unhealthy foods and beverages within government institutions. For example, New York City has developed a nutrition policy for all foods purchased, served, or contracted for by City agencies. Across the ditch, the New Zealand Ministry of Health has told all District Health Boards to stop selling soft drink in hospitals. Bans on junk food advertising in government-owned institutions, and on government-owned transport services, could form part of a package of measures that ensure that government agencies take a consistent stance on the importance of good nutrition and preventing weight gain. As noted by the ACT Minister for Territory and Municpal Services, if governments are seeking to promote healthier food to children, “leaving junk food advertising off the buses helps contribute to that overall objective of delivering a healthier message to our kids.”

The NZ Health Ministry has called on District Health Boards to stop selling soft drink.
The NZ Health Ministry has called on District Health Boards to stop selling soft drink.

Bundaberg Rum and Dora the Explorer: the reality of alcohol advertising in Australia

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A brief commercial break, then on with the show…

My 3-year old daughter loves Dora the Explorer.  She thinks that bossy little know-it-all, Dora, is really cool.  She used to be frightened of The Swiper, but that changed as she grew older.

Last night, I sat her down in front of a laptop and let her watch an episode of Dora on YouTube.  Right away an ad filled the screen for Bundaberg Rum.  Bundaberg Rum is a brand owned by Diageo Australia.  All of this happened mid-evening, before 9pm.

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This is the reality of alcohol advertising in Australia.  Liquor ads, bought and paid for by Australian drinks manufacturers, streamed online with children’s content.

It’s not unlawful.  It’s business as usual.

This is the kind of thing the Alcohol Advertising Review Board draws attention to in its latest report.

A product review by a 12 year-old for Vodka Cruiser Pineapple Passion Punch 2L, on the Dan Murphy website (owned by Woolworths). Johnny Walker and Smirnoff ads screened in cinemas  before “Minions” – an animated film, rated PG.  Alcohol ads plastered over bus stops outside schools (see p 17 of the report).  And so on.

If you don’t want your pre-schooler exposed to liquor ads while watching age-appropriate material online, what are your options?

First stop: The Alcoholic Beverages Advertising Code (ABAC).  According to ABAC, “The ABAC Scheme is the centrepiece of Australia’s quasi-regulatory system and is administered by a Management Committee which includes industry, advertising and government representatives.”

The ABAC Code and complaints scheme are not legally binding, but members of the Brewers Association of Australia and New Zealand, the Distilled Spirits Industry Council of Australia and the Winemakers’ Federation of Australia are signatories.

The ABAC Code places few real constraints on signatories, but it enables the alcohol industry to claim that alcohol advertising is regulated responsibly, at no cost to government.  Which would be great, if it were true.

The ABAC Code places no restrictions on the placement of an alcohol advertisement.

If you’re a drinks manufacturer who wants to advertise on the internet – including on websites that carry or are even devoted to children’s content – the ABAC Code has no problem with it.

For example, when Crown Lager ads appeared on a “Bratz” games website (and check out the URL to see what I mean ), the complaint was dismissed  because the ABAC Code was designed not to apply to the placement of alcohol ads.

An independent complaints scheme, the Alcohol Advertising Review Board, points out the limitations of the ABAC, and administers its own Codes, with help from a panel of lay members located around the country.

The Content Code is constructed from provisions in existing alcohol advertising codes from around the world.  The Placement Code, however, “features provisions by which the Board considers the placement of alcohol advertising should be governed”.

The Placement Code contains the following provisions:

1. Placement: General

Alcohol Advertisements should not be placed: (i) in places or at broadcast times where Young People are exposed or are likely to be exposed; or (ii) in connection with content that appeals to Young People.

8. Internet

Alcohol Advertisements shall not appear online in connection with content that appeals or is likely to appeal to Young People.

As a parent, those constraints appear entirely reasonable to me.

By the way, you have to love the “Drink Wise” logo in the second screen shot above.  You probably missed it.  After all, it was designed to be missed.

For further comment on this in the Sydney Morning Herald and Fairfax press, click here.

A Fairfax video reporting on this blogpost, containing the images included in this post, has now been added to YouTube.

AdNews has reported that Diageo has suspended all media across the YouTube platform while it investigates the matters raised above.

This incident provides an interesting opportunity to test the limits or otherwise of the ABAC Code.  Accordingly, I have submitted a complaint.

Are you interested in studying health law?  For further information on Sydney Law School’s Master of Health Law and Graduate Diploma programs, follow this link.

Local government action: a new pathway for obesity prevention in Australia

Mayor Mick Cornett launches
Mayor Mick Cornett launches “This City is Going on a Diet” in front of Oklahoma City zoo

Writing in the Sydney Morning Herald, Stephen Simpson (Director of the Charles Perkins Centre at the University of Sydney) and Rosemary Calder (health policy Director at the Mitchell Institute for Health and Education Policy at Victoria University), call for community-based action to prevent chronic disease. They point to communities like Broken Hill, which has high rates of obesity, but also a strong self-identity and good social cohesion, offering exciting opportunities for a community-led approach to prevention.

Steven Simpson and Rosemary Calder contrast community-led initiatives to government action, but maybe we could have both. Legislation and regulation could be much better used to support existing local initiatives, encourage community action, and improve local-level obesogenic environments. This is a relatively unexplored area in Australia, but there is growing interest in local level action in obesity prevention in some regions of the country. The City of Sydney encourages active transport, which it links to improving health in the city. The City of Marion, in Adelaide, implemented an obesity prevention program that included community meals and physical activity sessions, targeted to at-risk populations. And some states governments have moved to strengthen the role of local governments in health promotion through legislative measures. For example, South Australia’s Public Health Act 2011 makes local governments responsible (for the first time) for taking action to preserve, protect and promote public health within their area.

The US is much further ahead than Australia in local level prevention efforts, with states and municipal governments around the country trialling innovative obesity prevention policies. A US national prevention policy framework encourages local obesity prevention policies, as do federal grants for community-based initiatives. Local efforts in obesity prevention in the US could provide some lessons for Australian local governments that want to take action in obesity prevention, but they also illustrate some of the challenges that our local governments may face in taking legislative action.

High profile initiatives in the US have attracted significant media attention, as when the former Mayor of New York City, Michael Bloomberg, attempted to ban large sized sodas sold by food service establishments in the city. However these kinds of controversial initiatives are just the tip of iceberg. A range of state and local governments are experimenting with measures to improve the obesogenic environment and encourage physical activity, including Californian legislation that reduces taxes for landowners who make their land available for urban agriculture, and laws in Maine that require grocery stores to stock a minimum number of ‘staple foods.’ Some localities have introduced broad-ranging programs that combine infrastructure development, improved urban design, and health education. In this TED talk, Mayor Mike Cornett describes his obesity prevention strategy for Oklahoma City, and how it resulted in the loss of over one million pounds by city residents. Mayor Cornett also attributes his initiatives with encouraging economic revitalisation in the city.

There are many benefits to local level action. In both Australia and America, the division of powers between state, local, and federal governments enables local governments to act as ‘laboratories of innovation,’ i.e., to trial innovative policies without facing the political barriers that would impede federal-level initiatives (e.g., aggressive industry lobbying). Local governments use their legislative and administrative powers to develop policies that are tailored to the social, economic, and demographic features of their region, and which can diffuse ‘horizontally’ to other localities and ‘vertically’ – upwards to states and national government levels. Local leaders are closer to their constituents, allowing them to be more responsive to community needs, and facilitating ‘bottom-up’ initiatives that are built on a base of community consultation and ownership.

However, local policy making in the US illustrates some of the challenges that local governments in Australia may face in preventing obesity. As in Australia, local governments in the US are creatures of state government. Some US municipalities have expansive rule-making authority, but other states delegate only narrow powers, constraining local action and creating variation in the extent to which local governments can pursue obesity-prevention measures. Popular and media discourse frame obesity mainly as the result of individual’s poor consumption choices, meaning that government intervention to encourage healthy eating and drinking are often seen as paternalistic. Critics of the soda ban referred to Mayor Bloomberg as Nanny Bloomberg, and the soda portion rule was eventually declared invalid following a legal challenge.

Another concern is that some obesity-prevention strategies disproportionately impact vulnerable communities. Like tobacco taxes, soft drink taxes can be seen as regressive because they fall more heavily on lower-income groups who drink more soft drink and have fewer resources to absorb tax increases. Policies that actively target at-risk communities may also be discriminatory when they are based on ethnicity or race, as opposed to targeting neighbourhoods or communities with poor health indicators. Effective policies can also fail to reduce – or even exacerbate – health inequalities. Redesign of the urban landscape can increase gentrification, pushing low-income residents out of the inner city into areas with fewer amenities.

A final issue is that community-level prevention policies are a relatively new area of intervention and the results of evaluating studies are still emerging. Supporters of local-level innovation argue that policies such as the soda portion rule are supported by evidence linking soft drink consumption to diabetes and obesity, for example. However, many policies lack causal evidence to support their effectiveness in producing tangible obesity prevention outcomes. Yet some local initiatives have produced demonstrable changes in health-related behaviour and weight status, with particularly good evidence for school-based initiatives.

Despite these challenges, local government action could form the centrepiece of a revitalised approach to obesity and chronic disease prevention in Australia. Local government action is particularly important in Australia, where the current federal government appears entirely disinterested in chronic disease prevention (having recently cut funding for prevention efforts, including for local policies and programs), and some state governments are withdrawing from health promotion, and actively devolving preventive efforts to local governments.

Further, local government law making could be designed to address some the barriers outlined above. Health law academics in the US call for a participatory, inclusive approach to the design of public health law and regulation, where local communities are involved in identifying areas for action, as well as in processes of policy design and implementation. Their argument is that inclusive law-making processes are more likely to produce initiatives that reflect community interests, and have a strong base of community support, potentially ameliorating the concerns about nanny statism that attach to initiatives championed by public health’s ‘elites,’ such as Michael Bloomberg. Inclusive law making that is tailored to local concerns could also help to address health inequalities, while preventing initiatives from being perceived as discriminatory.

Local governments may provide a route for stronger action on prevention in Australia, particularly in light of the apathy of the current Liberal federal government. But if we are to frame obesity as a collective problem requiring community-based solutions, we need to reconceptualise public health law as a democratic, participatory and collaborative project that ensures recognition and supports self-determination for marginalized communities. Public health doesn’t need nannies; it needs local champions, facilitators, mediators, guides and leaders.