Smoke-free streets and lanes: a growing headache for big tobacco?

Smoke-free Melbourne?

One of Melbourne’s quintessential experiences is to stroll its laneways, many lined with restaurants.  Smoking here would spoil things for everyone.

In 2014, Causeway Lane, a small restaurant strip running between Bourke Street Mall and Little Collins Street, went smokefree.

You can read reactions to this smoke-free pilot here.

Three more laneways were added in 2015.

Victoria’s Local Government Act 1989 permits local governments, including the City of Melbourne, to make and enforce “local laws” (see ss 3E, 111) that relate to its functions or powers, provided they are not inconsistent with Victorian Acts or regulations.

The City of Melbourne’s Activities Local Law 2019, one of three local City laws, empowers Council to prescribe smoke-free (local) areas (see Part 3A). Click here for more information on City of Melbourne smoke-free places, and click here for a map of these places.

The City of Melbourne is currently reviewing community feedback about a proposal to make Bourke Street mall smoke-free.  See here, and here.

 

Smoke-free North Sydney

North Sydney Council has gone even further, voting in July 2019 to completely ban smoking in its CBD.

Community consultation showed 80% support in favour of the ban.

The traditional justification for second-hand smoke laws – in bars and restaurants, offices, trains and airplanes, is that smokers should not be permitted to harm the health of non-smokers.

With growing demand for fresh air, however, these laws have taken on a life of their own.

Area-wide smoking bans in public places are a logical follow-on from the decade-old smoking bans on Sydney beaches.

Manly beach went smoke-free in 2004, and all harbour and ocean beaches in Sydney’s northern beaches area are now smoke-free.

Bondi Beach also went smoke-free in 2004, and Waverley Council has since extended smoking bans to the Oxford Street Mall.

 

Conceptualising innovations in tobacco control

Second hand smoke controls reduce butt litter and harm to non-smokers, including asthmatics and others with lung and heart conditions.

It seems clear, however, that bans are expanding into areas where the risk of harm to non-smokers is substantially reduced.

It’s a process I call transformation: when the justification for existing legal controls changes over time as a result of norm change, facilitating further expansion.

These days, what functions do smoking bans serve?  Beyond causing harm to non-smokers, are they laws that relate to amenity – the desire of the majority not to have their enjoyment of public places spoiled by even transitory encounters with nasty tobacco smoke?

Or are they about reducing the potential for smoking to function as a socially communicable disease by reducing the visibility of nicotine-seeking behaviour?

Or are they about litter and protection of our waterways?  (I once saw a smoker put their butt in the bin.  Honest, cross my heart).

Or are they simply an exercise in “making tobacco use difficult” (to use Brawley’s term)?

Whatever the reasons, the nanny state theorists aren’t having a bar of it.

Residents’ demand for fresh air, and smokers’ recalcitrance on butt litter went down like “sick in a cup” with radio man Steve Price, who has blasted the ban as a “nanny state solution”.

Other ways in which tobacco controls can expand include through extension (where the purpose of the law remains the same, but the reach or intensity of legal controls becomes more extensive over time (as with prohibitions on tobacco advertising), and through creation (where law imposes distinctively new kinds of controls to help reduce initiation, encourage quitting, discourage relapse, and reduce exposure to second-hand smoke).

[a designated smoking area on Orchard Road, Singapore]

 

Smoke-free districts in asia

A similar trend towards smoke-free streets and precincts looks to be under way in parts of asia.

From 1 January 2019, the Orchard Road precinct in Singapore became a smoke-free zone.

Smoking has not been eliminated entirely along Singapore’s famous shopping strip.  But smokers are required to smoke in designated places, reducing litter, and further reducing non-smokers’ exposure to tobacco smoke in outdoor areas.

It’s a similar picture in Penang, Malaysia.  This wonderful world heritage city has gone smoke-free.

In the United States, Disney World and Disneyland are going smoke-free, and there are no designated smoking areas within these parks.

Not all tobacco control advocates are comfortable with the trend towards smoke-free public spaces.

Simon Chapman has argued that “banning smoking in wide-open public spaces goes beyond the evidence and is unethical”.

One interesting possibility is whether the failure to accommodate smokers’ nicotine addiction constitutes discrimination on the grounds of “disability” or “impairment” under NSW, Victorian and other anti-discrimination or equal opportunity statutes.

While opioid addiction has been considered a disability under the Disability Discrimination Act 1992 (Cth) [see commentary here], nicotine dependence has not yet been regarded as a “disability” or an “impairment” for the purposes of State anti-discrimination laws (see here, and here).

I’m not sure tobacco companies want all their addicted customers categorised as disabled, but you never know.

In the meantime, enjoy the fresh air!

[No smoking in George Town, Penang’s World Heritage site]

Interested in studying health law?  Click here and here for more information.

Put another Winfield on the Barbie

Having actor Paul Hogan headline Cure Cancer’s “Barbecure” makes no sense to me.

Put another shrimp on the barbie, I get it.  But so what?

Hogan may regret the staggeringly successful “Anyhow, have a Winfield” advertising campaign he headed in the 1970s, but his presence in a cure cancer campaign is inept.  It muddies the message.

Winfield is a brand of cigarettes now owned by British American Tobacco Australia.

Of his former campaign for Winfield, Hogan has said “Yeah, we were encouraging people to smoke.

“Young ones were taking up smoking and all going for Winfield. It was a staggering success but I was a drug dealer. But who knew then?”

This is not to suggest that Hogan is not sincere in wanting to help.  I’m sure he is.

But why does an organisation raising funds to support cancer research ask one of the most effective promoters of tobacco in Australian history, someone who is still, apparently, a smoker – to front the campaign?

Curing cancer…a tale of two strategies

Cure Cancer’s Barbeque concept seems to be about raising money for what we might call “techy” solutions to treating cancer – funding research towards a new drug or therapy.

(Must say, though, I love the idea about hosting a barbie, telling the guest list they’re not invited and hitting them for hard cold cash instead).

Cancer research is, of course, worthy and deserving of funding.  Who knows, many of us may one day benefit from such research and the therapies that result.

But there’s another way to cure cancer as well…it’s called reducing the risk that Australians will get cancer in future.

Using smart public policies, we can prevent the risk that Australians will get heart disease, and diabetes too.

Unfortunately, preventive health enjoys a fraction of the profile – and almost none of the money – that techy solutions like research towards new drugs or therapies attract.

This could be because one important dimension of prevention at the population level is regulation, and that makes prevention a political matter.

Australia has a pretty shabby record in using law and regulation to reduce modifiable risk factors for the non-communicable diseases that are responsible for the overwhelming share of death and disability in this country.

When it comes to food and diet-related risk factors, for example, see the scorecard and priority recommendations for Australian governments issued by the Global Obesity Centre, a WHO Collaborating Centre for Obesity Prevention, at Deakin University.

How many lifetimes till these are implemented, I wonder?

A decade ago, the National Preventative Health Taskforce released a blueprint for improving the health of Australians.

I can no longer find that report on the Australian Government’s website.

Although the government has raised the excise on tobacco and implemented plain tobacco packaging, no formal targets have been set for reductions in obesity or dietary risk factors, and prevention policy has been described as “flapping in the wind” (Swannell 2016).

Preventing cancer is “curing” cancer too

The Australian Preventive Health Agency, which was established to spearhead preventive efforts, and to fund preventive research, was de-funded and is extinct.

This move damaged momentum on preventive health in Australia, as Leeder, Wutzke, and many others have pointed out.

Which is a shame, because preventing cancer is “curing” cancer too.

Are you interested in health law?  Sydney Law School offers a Master of Health Law with mid-year entry.  See here and here for more information.

A Foundation for a smoke-free world…funded by a cigarette multinational: more smoke and mirrors?

The Swiss like butter on both sides of their toast.

Headquartered in Lausanne, half an hour’s train ride from the World Health Organisation in Geneva, you’ll find the headquarters of the world’s most profitable tobacco company, Philip Morris International (PMI).

Makers of Marlboro and other global brands.

A few years ago, at the end of a very long interview, held in the PMI Boardroom, I asked a senior PMI executive what he would most like to tell the public health community.

This gentleman, although friendly and accommodating, had smoked all over me for three solid hours.

He said:

“I would like the public health community to try to spend some time listening to what Philip Morris has to say and to see whether or not we can reach some kind of agreement… I think if we continue to fight as opposed to try to reach an accord, we’re losing an opportunity, and I think that Philip Morris has a lot to offer that can help shape and develop regulation, but the public health community has [got] to get beyond its pre-conceived notion that anything that Philip Morris or any other tobacco company proposes is immediately suspect and inappropriate.  That would be my number one concern…”

The wish of this PMI executive was the same as that of every other tobacco executive I spoke to: he wanted governments and public health advocates to listen to his company.  He wanted to partner with the public health community, he wanted a role in shaping policy and regulation.  He wanted “the war” to end.

Philip Morris International may be a step closer to this aim with the launch of a new entity called the Foundation for a smoke-free World.

 

Foundation for a Smoke-Free World

Founded by Derek Yach, the former head of the WHO’s Tobacco Free Initiative, the Foundation was launched with a promise of US$80 million funding per year for 12 years from PMI.

The aims of the Foundation are to “advance smoking cessation and harm-reduction science and technology”.  These aims appear suitably aligned with PMI’s strategy of eventually replacing cigarettes with smoke-free products, and in order to get there, lobbying governments to give preferential treatment to non-combustible recreational nicotine products.

PMI’s website states that: “we don’t agree that banning cigarettes makes sense for smokers or for society at large.”

But speaking of the success of IQOS (a heated tobacco product manufactured by PMI) in South Korea and Japan, PMI CEO André Calantzopoulos suggests that in five years, as users of heated devices outnumber smokers, “That is when we could start talking to governments about phasing out combustible cigarettes entirely.

They’ve taken their time sharing it with us, but according to Philip Morris, there is an answer to the tobacco epidemic.  It seems you won’t find it in the World Health Organisation’s Framework Convention on Tobacco Control, nor in generations of experience with evidence-based tobacco control laws and policies.

Rather, the answer lies elsewhere:

Individual risk reduction X consumer switching = population harm reduction.

In particular, PMI wants smokers to start using IQOS, the first of four smoke-free products it is (apparently) building its future on.

Of course, PMI needs governments to play their part as well.

We are confident that the right mix of government leadership and commercial initiative will dramatically accelerate efforts to reduce the health burden of smoking.

Which is why, I suspect, substantial funding to the Foundation for a Smoke-free World makes sense at this time.

 

Independent?

The centrepiece of the Foundation’s claim to independence is the article on scientific integrity in its by-laws, which states:

“The goal of the Corporation is to promote and support significant scientific research that advances the field of tobacco harm reduction and reduces the public health burden of smoking-related diseases.  The Corporation shall not take into account the potential impact of that research on the image of the tobacco industry or any other industry or commercial entity”.

That sounds good, doesn’t it, if they can manage it?

The problem is that the funding for this Foundation would appear to depend on annual or periodic renewal by a tobacco multinational.

And that is howlingly significant.

The existence of the Foundation, certainly its size and clout, will depend on how the activities and results of the Foundation appeal to PMI’s board.

That may not be such a risk if you’re married to a vision of tobacco harm reduction that involves promoting the recreational nicotine products that PMI wants to flog around the world.

According to PMI CEO André Calantzopoulos, “The Foundation is a welcome driver of change, at a time when a smoke-free future is clearly on the horizon. We will welcome its recommendations to accelerate smoker adoption of less harmful alternatives.”

No doubt.

But if the Foundation, in all its independence, were to fail to effectively prosecute the case for harm reduction in a form that benefits PMI’s business case, surely the Board would re-consider its investment.  It would be mad not to.

 

No accident

The Foundation for a Smoke-free World has appeared at a time of unique risk for makers of e-cigarettes and heated tobacco products.

I would expect that part of the Foundation’s work, pursuant to its harm reduction agenda, would be to encourage governments to make e-cigarettes more available (in jurisdictions, like Australia, where they are banned), perhaps to tax them at a lower rate, and certainly to reverse the tendency seen in jurisdictions like California to apply smoke-free laws and minimum purchasing age restrictions equally to both cigarettes and non-combustible nicotine products. (See references to California’s legislation in a previous post).

In October, New York State became the latest U.S. state to ban use of e-cigarettes in restaurants, bars and indoor public places including workplaces.  (See here for the text of the legislation).

Addressing this dangerous tendency, and promoting a regulatory environment that allows recreational nicotine products to thrive, is best framed in terms of “saving lives”.

Australia’s Health Minister, Greg Hunt MP, has stated that he will not lift the ban on e-cigarettes: “not on my watch”.

For that, I believe, he deserves credit.

We can expect a gush of Foundation-funded research, ultimately paid for by Philip Morris, arguing that e-cigarettes and heated tobacco products save lives.

Rather than focusing on implementing the evidence-based controls in the Framework Convention on Tobacco Control, governments will be encouraged to switch strategy towards tobacco harm reduction, which translates into relaxing controls on the products that make PMI shareholders rich.

The World Health Organisation claims the Foundation has conflicts of interest and states: “WHO will not partner with the Foundation. Governments should not partner with the Foundation and the public health community should follow this lead.”

In the end, whatever the Foundation and its leaders think they are doing, given the scale of PMI’s investment, the  Foundation will perform a massively important public relations function for its economic parent.

These PR functions are important, given that in the here and now, PMI remains firmly in the cigarette business, exploiting markets around the world where tobacco control laws remain weak (see eg Kalra et al in Reuters).

 

Reaction to the Foundation for a Smoke-free World

To say that the launch of the Foundation has been taken badly by NGOs and global leaders in tobacco control is something of an under-statement.

Distinguished Professor of Tobacco Control at UC San Francisco, Stanton Glantz, writes that “Derek Yach’s journey to the dark side is now complete”, pointing out that PMI’s funding of the Foundation represents “about .1% of PMI’s revenues and 1% of its profits”.

Ruth Malone, Simon Chapman and colleagues write:

“This ‘new’ initiative is just more of the same lipstick on the industry pig, but in a way it’s far worse this time: by using a formerly high profile WHO leader as a spokesperson, PMI can also accelerate its longstanding ambition to splinter the tobacco control movement”.

WHO points out that if PMI supported a smoke-free world it would support evidence-based tobacco control policies that help people quit smoking, including tobacco taxes, graphic disease warning labels, and comprehensive bans on tobacco advertising, promotion and sponsorship.

These are building blocks of successful tobacco control.  They work.

The reality, in jurisdictions around the world, is that PMI opposes these measures.

Outside of rich western markets, where health considerations predominate, it’s business as usual for Philip Morris International and for Marlboro, their star brand.

(Marlboro advertising in Jakarta, Indonesia; the photo at the top, from the island of Lombok, is typical of advertising by Philip Morris International throughout the archipelego)

 

California raises the minimum purchase age for cigarettes and e-cigarettes

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Last week was a big week for those who think the law should have a role in helping to reduce the 6 million deaths caused each year by tobacco.

First, tobacco taxes

In 2013, the Rudd government announced a 12.5% increase in the tobacco excise to take effect over 4 years:  1 Dec 2013; 1 Sep 2014; 1 Sep 2015; 1 Sep 2016.

Scott Morrison’s 2016 budget will continue this increase for a further 4 years (2017-2020), taking the price of a pack of 25 cigarettes to around $41 in 2020.

These excise tax increases will be in addition to the usual, bi-annual indexation of excise in accordance with average weekly earnings.

As recognised by the WHO Framework Convention on Tobacco Control, which Australia has signed, tax and price measures are a powerful, cost-effective tool for reducing tobacco consumption, particularly among young people.

Secondly, more wins on tobacco plain packaging

The European Court of Justice has upheld the right of Member States of the European Union to pass plain tobacco packaging laws that exceed the requirements for the standardisation of tobacco packaging contained in the European tobacco products directive.

The Directive includes a requirement for mandatory health warnings, comprising text and colour photographs, covering 65% of the back and front of tobacco packages (Art. 10.1).

Article 24.2 of the Directive preserves the right of member states to introduce further requirements for the standardisation of tobacco packaging “where it is justified on grounds of public health, taking into account the high level of protection of human health achieved through this Directive”.

These further measures must be proportionate, and must not be a disguised form of trade restriction.

The ruling of the Court paves the way for the UK’s tobacco plain packaging legislation (the Standardised Packaging of Tobacco Products Regulations 2015 to become mandatory for all tobacco products on 21 May 2017.

Following Australia’s Tobacco Plain Packaging Act 2011 (Cth), plain tobacco packaging has become an export industry, with Ireland also adopting legislation in 2015.

California raises the minimum purchase age for tobacco

But perhaps the most interesting development is the creeping advancement of higher tobacco purchase laws for tobacco within the United States.

On 4 May 2016, California Governor Jerry Brown signed 2 Bills into law that confirm California’s leadership in tobacco control.

Senate Bill No 7 prohibits the sale of tobacco products in California to persons younger than 21 years.

The Bill includes an anti-pre-emption provision giving freedom to local governments to raise the minimum purchasing age even higher.

With a republican-controlled Congress hostile to public health measures, it has fallen to local and city governments, and to States, to innovate and to protect the health of their populations.

California’s action follows the lead of Hawaii and over 125 local and city governments that have passed legislation to raise the minimum purchase age for tobacco to 21.  This trend is likely to continue, both in the United States, and possibly elsewhere.

The California Bill contains an exception for Military personnel in active duty who are aged over 18 but under 21 years.

This is not the first time U.S. legislatures have bent the rules to facilitate smoking by members of the US armed services.

California Senate Bill No. 5, also signed into law, expands the definition of the term “tobacco products” in the Business and Professions Code to include e-cigarettes, and requires retailers to pay a licence fee to sell e-cigarettes.

It requires all cartridges for e-cigarettes to be in child-resistant packaging;

It also extends the smoke-free controls applicable to cigarettes in California, to e-cigarettes – a regrettable omission in the Public Health (Tobacco) Amendment (E-cigarettes) Act 2015 (NSW).

The California Bill also prohibits selling or advertising or furnishing e-cigarettes to persons younger than 21 years.

Time to raise the minimum purchase age for tobacco in NSW?

Raising the minimum purchasing age for tobacco is a sensible next step towards a tobacco-free generation that is healthier and more productive.

Higher minimum purchasing age laws make sense, since few smokers begin smoking or become addicted to nicotine beyond the vulnerable mid to late teens and early twenties.

A 2013 study of smoking initiation rates in New Zealand confirmed that while initiation after age 24 is rare, the highest initiation rates occur among those aged 15-21 years. Over a four-year period, the rate of smoking initiation for those aged 15-17, 18-19, and 20-24 was 14.2%, 7.0%, and 3.1%, respectively.

An expert Committee of the Institute of Medicine concluded that raising the minimum purchasing age would substantially reduce smoking prevalence and smoking-related mortality, given the numerous life transitions young adults experience between 18 and 20 years.

It could also help to improve foetal, maternal and infant health, by reducing the numbers of young parents smoking.

The Tasmanian Government has released a 5-year strategic plan for health that includes raising the minimum legal smoking age to 21 or 25 as an option for consideration.

Such laws could help to reduce health inequalities.  For example, according to Tasmania’s Council of Obstetric and Paediatric Mortality and Morbidity, more than 33% of Tasmanian teenage pregnant women are smokers (2013 figures).

Raising the minimum purchase age for tobacco would not be costly to implement, although resources should be budgeted for its enforcement, and this includes close monitoring and evaluation of its net effects.

Think about it.  Will there be any parents, including smoking parents, who wish their child had been able to buy smokes on their 18th birthday?

Conversely, how many 30 year olds – facing the economic challenges of life, including breaking into the property market – will be thankful they missed the bullet of nicotine addiction and aren’t now making generous weekly donations to Australia’s tobacco giants?

Are you interested in studying health law?  Sydney Law School offers a Graduate Diploma and a Masters degree in health law that is open to qualified applicants.  For further details, click here, and here.

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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Our new Nanny State? The Senate inquiry into tobacco, alcohol, and bicycle helmet laws

New Yorkers’ had a Nanny. Do Australians have one too?

Earlier this month, Senator David Leyonhjelm announced aSsenate inquiry into legislative and policy measures introduced to restrict personal choice “for the individual’s own good,” including laws related to tobacco, e-cigarettes, alcohol, marijuana, bicycle helmets, and film classification.

Leaving to one side the irony of a government inquiry into government’s unreasonable interference in our lives, many of the products to be considered by the inquiry are of central concern to public health. Smoking remains Australia’s largest preventable cause of death and disease, responsible for some 15,000 deaths, and costing Australia $31.5 billion in social and economic costs annually. Alcohol is linked to over 60 different health conditions, and accounts for around 3430 deaths per year.

Public health advocates call for a strong government response to these health problems, because preventive measures are more cost-effective than treatment, and because legislative and policy measures work.

Laws and regulations concerned with restricting the sale or promotion of cigarettes and alcohol are often seen as examples of the “Nanny State” in action, i.e., unwanted government interference in what should be our own, freely-made choices. But it’s wrong to frame these measures simply as the state acting “for the individual’s own good.” Governments have a legitimate interest in ensuring population health, and in preventing the healthcare costs associated with alcohol and tobacco consumption. So too do we, as taxpayers.

Governments also act a check on the powerful corporate interests that have a profound influence on our drinking, smoking, and eating habits. We might as well ask, why isn’t there an inquiry into Big Tobacco and Big Alcohol, and their impact on our freedom to live healthy, productive lives?

It’s possible for governments to overstep their boundaries, and to introduce measures that are overly paternalistic and completely out of step with community needs. But by adopting the prejudicial language of “personal choice” the Senate inquiry seems to have closed itself off already to the kind of useful debate that we might have about the role of the modern state in protecting population health.

Perhaps the inquiry should consider a new collection papers published in the journal Public Health under the heading “Who’s afraid of the Nanny State? Freedom, regulation, and public health.” This special issue explores and unpacks the meaning of the Nanny State rhetoric so beloved by Senator Leyonhjelm, drawing upon work by academics from a variety of disciplines. It offers new ways to conceptualise the role of the state, and highlights the vast array of tools available to governments when acting to protect public health.

Don’t be fooled by the rhetoric. Laws and policies on bicycle helmets, cigarettes, and alcohol save lives. And they do so in a much less intrusive way than chemotherapy for lung cancer, a liver transplant, or surgery for traumatic brain injury.

A tiny illustration of what the tobacco industry is like

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Click on this link.  It’s a tiny illustration of what the tobacco industry is like.  It ought to be placed on the health curriculum of every school.

Professor Stephen Leeder once wrote that public health is a “contest of raw political power” (S.R. Leeder, “Ethics in public health” Internal Medicine Journal 2004; 34:435-439).  Basically, it’s WAR!  He’s right.

(And if you ever doubted it, read this).

The document I’m referring to was written by the owner and manager of E. M. Bowman & Co, Flinders Island’s longest established general store.  It is a submission to a Parliamentary Committee of the Legislative Council of the Tasmanian Parliament, which is holding hearings into the Public Health Amendment (Tobacco-Free Generation) Bill 2014.

Tasmania’s smoking rate is second-only to the Northern Territory, with daily smoking prevalence of 20.6% in 2011-2012.  The Tobacco-Free Generation Bill proposes an endgame scenario for tobacco in the state.

The Bill proposes to amend Tasmania’s Public Health Act 1997 (Tas) by creating an offence for selling tobacco at retail, in Tasmania, to a member of the “tobacco-free generation” (s. 67J).  The Bill defines a “member of the tobacco-free generation” as a person born after 1 January 2000.  The Bill does not have the support of the Tasmanian government.

The Bill would not prohibit smoking by those born after 1 January 2000.  However, as time went on, the impact of the legislation would be that:

  • adults who were older than the current year (eg older than 21 years during the year 2021) would, by virtue of being born before the year 2000, be able to continue to purchase tobacco during their lives;
  • On the other hand, adults of the tobacco-free generation, who would be the same age, or younger than the current year (eg aged 21 in 2021) would never be entitled to purchase tobacco lawfully in Tasmania.

You can read all the submissions about the Bill here.  This post does not focus on the merits of the Bill.

In her submission, Ms Lois Ireland, owner and manager of E M Bowman and Co, writes how she was contacted by Imperial Tobaco, which attempted to co-opt her into lobbying the Legislative Council against the Bill.

Ms Ireland writes:

“I made a conscious decision to stop gaining a profit from sales of a product that I knew to be highly addictive and that was causing long term health issues with those who I knew personally as members of my community.  I knew they would go elsewhere to purchase their cigarettes but I did not wish to be further implicated in their poor health choices.  As a result I fully endorse any moves that make it more difficult for young people to take up/continue smoking, despite any effects such measures may have on businesses”.

Ms Ireland’s submission to the Parliamentary Committee illustrates two important lessons.

First, it is one, tiny, local example of a global phenomenon: the relentless efforts of tobacco companies to undermine, weaken and resist tobacco control laws and policies, and to identify proxy lobbyists to assist them in doing so.

Secondly, it illustrates a singular act of courage by a retailer whose revenues would have been reduced by the value of the tobacco she chose not to sell.  But she did it anyway.

If you ever visit Flinders Island, make a point of stopping in to E M Bowman & Co.