Monday, March 28, 2005

IN MY VIEW: Smokers are Not the Problem - Let's Not Treat Them That Way

I have received a number of comments regarding my views that: (1) increasing cigarette taxes to fund non-tobacco-related projects is inappropriate public health policy; and (2) policies that make off-the-job smoking a criterion for employment decisions are generally inappropriate. I therefore thought it might help to explain how I have come to these views.

I am in the field of tobacco control because as a physician, I view this as the way in which I can work to promote the best interests of the patient. I entered tobacco control because such a large number of my patients were smokers and it became clear that preventing smoking and encouraging smoking cessation on a population-level were the most important goal I could pursue. I also spent two years working in a methadone maintenance clinic and observed the difficulty my clients had overcoming their addiction to cigarettes, which was every bit as strong as their addiction to heroin, cocaine, alcohol, or other drugs. Thus, from my background and experience, I view smokers not as the problem, but as the patients or clients who I am trying to serve through my public health practice.

Now the types of policies that one supports may be different if one views one's role as helping patients who smoke, rather than if one views smoking, and therefore smokers, as a public health problem. I view tobacco products (and the manufacturers of those products) as the problem, not the act of smoking those products, and certainly not the smoker (the majority of whom we know are addicted to the product).

This is the perspective I bring to bear in analyzing public policies regarding the regulation of smoking and tobacco products. In this light, employee policies that refuse to hire smokers, fire employed smokers, or impose excess charges on employees who are addicted to nicotine are not public health policies. They do not appear to me to be crafted in the interest of addressing the problem of tobacco products. Instead, they appear to me to be crafted in the interest of punishing smokers for a behavior that I as a physician know is a powerfully addictive one that is extremely difficult to stop. (Here I am referring to policies regarding smoking off-the-job; smoking in the workplace and/or on-the-job are appropriate areas of workplace policy, as are many aspects of lawful employee behavior).

Similarly, policies that use smokers as a way to fund programs that we as a society should be funding anyway do not appear to me to be crafted within the confines of purely public health interests. I think support for these policies is largely a political decision, in which public health organizations are using the economic benefits of an increased cigarette tax to the state to achieve a particular end. Since there is available an alternative policy that would achieve the same end but in a way that is not regressive and does not punish the most heavily addicted and often the poorest smokers, a decision to support the kinds of cigarette tax increases for which many public health groups are now advocating implies to me a rejection of the more sound (from a public health perspective) alternative.

I think our evaluation of these policies reflects more than just our specific views on the most immediately relevant concerns. It also reflects the overall paradigm with which we practice. The way in which we frame the problem has implications for how the public views the problem. While it may not seem that supporting policies such as Weyco's that fire smokers is relevant to the overall practice of tobacco control, I think that the public perception of our actions is an important result that must be considered. If our positions on issues tend to frame the problem as one of individual behavior, then that's the way the public will tend to view the problem as well. And that is going to eventually become an obstacle to the promotion of the most important and potentially most effective tobacco control policies.

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