In a strategy discussion reminiscent of the type of actions we in tobacco control often criticize the tobacco companies for engaging in, anti-smoking groups successfully hid from the public awareness of strong internal dissent within the tobacco control community regarding policies by which employers refuse to hire smokers.
In the wake of the World Health Organization's (WHO's) decision to refuse to hire smokers, there was a vigorous internal debate involving a number of anti-smoking groups and advocates on a list-serve of which I was a member. A fair number of tobacco control practitioners expressed strong opposition to what they considered to be a discriminatory policy that unduly intruded into employee privacy in the home and did not represent an appropriate public health intervention.
A number of discussants attempted to facilitate a vote in order to provide a somewhat objective indication of the position of anti-smoking groups and advocates on this policy issue, so as to gauge the position of the tobacco control community on the policy and inform WHO of where public health groups stand on its seemingly controversial decision.
Such information would be very useful and important for the public, the media, policy makers, and employers to have in order to help inform their decisions regarding the public health appropriateness of adopting such policies.
I observed this debate with great interest (I actually did not start the discussion or participate directly in it) and initially, I thought it was a good example of meaningful discussion and dialogue within the movement about an important policy measure. However, to my great surprise (at the time), the entire discussion was coopted by a bloc of adamant groups and advocates which stifled further debate, attacked the dissenters, and resisted any vote or any public revelation that there was indeed dissent about this important matter within the tobacco control community.
These groups were successful not only in putting an end to the debate, but also in stopping a vote on the issue and allowing any knowledge of the dissent with the tobacco control community to be brought to public attention.
The most interesting aspect of this story was not the stifling of debate on the issue, but rather the reasons provided for not assessing the views of tobacco control practitioners. Here are some examples of the arguments advanced for blocking any vote on the issue, followed by some commentary:
"If a poll is taken on the WHO policy, we should anticipate its results (which will be a split, regardless of the outcome) are likely to become grist for a blog and websites of FORCES and Forest, amid editorials espousing a right-to-smoke that is under attack by the anti smoker cabal. And if a majority polled oppose the WHO policy, we should anticipate significant media coverage pitching the story as a conflict between the WHO and some anti smoking advocates. Meanwhile, tobacco industry executives would have a good laugh as they send more checks to Lewis Maltby, dust off their right-to-smoke legislation from 15 years ago, and consider coalition building and lobbying budgets in more states and nations. Although I agree that further debate on XXX over the WHO policy probably won't be productive, the larger public policy issue regarding [smoker-free employment policies] and right-to-smoke legislation is unlikely to go away, and could further divide tobacco control advocates. ... I'd prefer debating our differences here on XXX [rather] than in state legislatures or in the news media."
Let's not find out how much dissent there is in the anti-smoking movement about these policies because if we do, it's going to harm our efforts to advance these policies. Knowledge of the internal dissent will become public, as it will appear on Mike Siegel's blog as well as the FORCES and other smokers' rights websites. We shouldn't ever expose to the public that we disagree about anything. It's important that any disagreement with the prevailing dogma and agenda of the movement remain hidden from the public so that it doesn't interfere with the advancement of this agenda through legislative policy enactment. Any dissent must only be expressed internally; dissenters cannot publicly state their views or they are helping the tobacco industry advance their cause. Even though we know that the movement is split on this issue, those who are taking the stronger anti-smoking position which penalizes smokers more must prevail and those who oppose the stronger position should keep their thoughts to themselves or share them only with other anti-smoking advocates.
"A XXX vote on the WHO hiring policy will help only the tobacco cartel. Sorry, I just had to yell that, I am so worried about a possible vote. If one happens, I will not vote, and I will urge all WHO policy supporters to not vote as well. It will not help tobacco control people in any way. We already know a small number of us are very vocal and on opposite sides of this issue. I do not want to fight new legislation on this issue again. I have much more important issues to work on. A XXX vote may lead to the tobacco cartel introducing more smokers' rights bills throughout the world. Those who promote a vote should be required to tell us if they or their close family members smoke or use tobacco, and if their company has or will take money from a tobacco company. XXX, XXX, XXX, XXX, XXX, XXX, XXX, XXX, XXX and others [most of whom had spoken out against the WHO's policy], when was the last time you had a smoke or spit tobacco? Have or will you and/or your companies take money from any tobacco company - including Kraft and all of their other subsidiaries?"
We must not let the public know that there is any dissent about the prevailing anti-smoking agenda. If the majority decides to have a vote, we must sabotage the process to avoid knowledge of dissent from becoming public. Dissent is simply a diversion from the important work that the rest of us in tobacco control are doing to actually advance the cause. Besides, anyone who opposes this anti-smoking policy must, by definition, either be a closet smoker or smokeless tobacco user or be on the Big Tobacco dole in some way. You can't go against the grain of the prevailing anti-smoking agenda and be a respectable individual. Even those who simply want to exercise the democratic process and are promoting a vote here must be either closet smokers or tobacco stooges.
"Other than allowing people to blow off steam, I do not see what a poll would accomplish other than giving FORCES et al grist for its mill."
Those who oppose the prevailing agenda of the movement are simply full of steam. They and their views should not be taken seriously and should not be allowed to get in the way of what the cool-minded majority of the movement is trying to accomplish. Allowing it to be known that there is significant dissent in the movement will provide ammunition to our enemies, so we must not allow knowledge of the dissent to become public.
"I also agree that a vote would be counter productive, for all the reasons that have been mentioned. ... It would be tragic for us, would it not, to do something that likely would invite criticism from FOREST and the like, and not even produce something meaningful? I had hoped in a prior posting to offer some 'talking points' framed in the form of questions which could be used by anyone, whether they agree with WHO's policy or not, in the event someone is confronted with a question about the policy and doesn't feel comfortable answering directly. You will also learn where the other person stands, rather than tipping your hand. As the person asking the questions controls the conversation uncomfortable conversations can be redirected towards the damage done by the tobacco industry."
Finding out how public health practitioners feel about an anti-smoking policy is tragic if it reveals that the policy is widely opposed. I am trying to provide those who oppose the WHO's policy with instructions on what to say if someone asks you how you feel about the policy. Rather than telling them that you oppose the policy, instead you must avoid the question and focus only on how terrible the tobacco industry is. Don't let on that you oppose any anti-smoking measure; simply repeat the dogma about how awful Big Tobacco is and move on.
"The fact is the WHO has adopted this policy at the highest levels. There are more productive things to do than fight with them."
We should not speak out against any anti-smoking policies that any group or organization promotes or adopts, even if we think that the policy is completely unjustified, discriminatory, and unduly intrusive and inappropriate from a public health perspective. Dissent interferes with the agenda and the movement and is therefore not productive.
The Rest of the Story
I could not, with any conscience at all, sit by and observe this take place and not bring it to public attention. I believe that we, as public health practitioners, are public servants and we have the ethical obligation to be truthful and transparent in all our actions, especially when what is at stake is so vital to the public interest as the potential of depriving smokers of the opportunity to seek gainful employment and to support themselves and their families.
There are three core ethical principles of public health and tobacco control which I think have been violated by anti-smoking groups, and I feel that these ethical violations require me to reveal the truth to the public.
Two of these core ethical principles have been spelled out in a recent Tobacco Control article (see Fox BJ. Framing tobacco control efforts within an ethical context. Tobacco Control 2005;14[Suppl II]:ii38-ii44). One is spelled out in the APHA Code of Ethics.
While it may seem obvious, I think it is worth being explicit about the fact that truthfulness is an important aspect of ethical behavior, not only by individual practitioners but by public health organizations. As Brion Fox points out in his outstanding review of ethical principles in tobacco control practice, if organizations fail to be truthful, they will actually be doing a disservice to the public: "Hence the tobacco control community must hold this principle sacrosanct and strive for disclosing the whole truth, otherwise it may lose its credibility."
This is similar to truthfulness, but it entails something more. Not only must public health organizations be truthful about the facts that are relevant to judging a public health intervention or policy, but they must also be forthright about the relationships and process by which these interventions or policies came about. As Fox argues: "The tobacco control community should strive for transparency in its dealings. If the tobacco control community fails to explain its dealings within an appropriate framework, it may be perceived as biased or hiding relationships, and it could lose its reputation for independence."
3. The Community-Level Equivalent of the Principle of Informed Consent
Just as public health organizations must provide individuals with full and accurate information before enrolling these individuals in research studies, public health organizations must also provide the public with full and accurate information that is necessary to make decisions on policies that affect them. This is what the APHA Public Health Code of Ethics calls the "community-level" equivalent of the individual-level ethical principle of informed consent:
"Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community'’s consent for their implementation. ... there is a moral obligation in some instances to share what is known. For example, active and informed participation in policy-making processes requires access to relevant information. ...Such processes depend upon an informed community. The information obtained by public health institutions is to be considered public property and made available to the public."
I believe that anti-smoking groups have violated the ethical principle of truthfulness, because they have not been truthful about the fact that there is tremendous dissent in the tobacco control movement about whether policies by which employers refuse to hire smokers are justified and appropriate public health measures. I believe that the public is entitled to know the truth about where public health practitioners stand on this important policy question. Deceiving the public into thinking that public health is unified in its support for such policies by attempting to cover up the fact that there is widespread dissent is, in my view, unethical.
I believe that anti-smoking groups have violated the ethical principle of transparency, because they have not been forthright about the internal discussions that have led to the current positions of the anti-smoking movement that has been communicated to the public. If the public were aware of the process that took place within the public health community regarding the debate over smoker-free employment policies, I think this would make a critical difference in the societal consideration of these policies. Thus, I think the public has the right to know what transpired.
I believe that anti-smoking groups have violated the ethical principle of informed consent. As APHA stated, "active and informed participation in policy-making processes requires access to relevant information. ...Such processes depend upon an informed community. The information obtained by public health institutions is to be considered public property and made available to the public." In this situation, the information obtained by public health institutions (that there were very strong arguments suggesting that smoker-free workplace policies are discriminatory, unduly intrusive, and unjustified and that a large number of public health practitioners hold such views) was not only not made available to the public, but there was an attempt to cover-up this information and prevent it from reaching the public.
This story illustrates how the anti-smoking movement deals with dissent. I have argued recently that there is no room for dissent in the movement, and some have suggested that my conclusions are not supported because they are based only on my own individual treatment in the movement.
Here, however, we can see how dissent by a large number of individuals was treated. Quite the same as my dissent has been treated. Discredit the dissenter, but do not address his or her actual argument. Criticize the dissenter for dissenting and make it unacceptable for him to let his dissent be known. Attack the dissenter and accuse her of being a tobacco stooge. Criticize the dissenter for causing a division within the movement and hurting our overall goals.
The strategy is finely-tuned and executed proficiently and to a tee. It works, and it carries the day.
The public is left with the perception that the anti-smoking movement supports policies such as the World Health Organization's, which takes job applications from smokers and automatically tosses them in the garbage, regardless of the individual's qualifications for the job in question, and even if the individual's smoking has no direct bearing on his or her qualifications for employment. Employers are left with the perception that smoker-free policies are viewed as being pro-public health, that these policies are viewed as being justified from a public health perspective, and that they will be praised in public health circles if they adopt such policies.
There is another aspect to the actions of these anti-smoking groups that I find unethical. And that is their support for these policies in the first place. I view employment discrimination as being ethically indefensible. There is no moral justification I am aware of for discriminating against a class of individuals simply because of the group to which they happen to belong, when belonging to that group does not directly or necessarily impact their qualifications for the job.
But to try to advance these discriminatory policies by hiding from the public the arguments against these policies and the fact that these arguments are being advanced by knowledgeable, reputable public health and tobacco control professionals and organizations, is most unethical, at least in my view.
I refuse to be a part of this, because I feel that if I remain silent, then in some way, I am an accomplice to the action of conspiring to hide this important information from the public.
This is an important glimpse into how the anti-smoking movement works in 2006. The movement needs to be reformed, because this type of behavior by public health organizations serves no public health interest of which I am aware. And more importantly, it violates the trust that the public has in our public health organizations and the actions that these groups are supposed to be taking to inform them of important facts about public health policies and to protect the best interests of their health and well-being.