In my last post of 2011, I suggested that the anti-smoking movement has recently changed from a focus on fighting tobacco smoke exposure to a near obsession with fighting smokers themselves. This is evidenced by policies such as those which ban smoking in large, wide-open outdoor areas such as Central Park or entire areas of a downtown and by policies which ban smokers, rather than just tobacco smoke, from the workplace.
I argued that: "These policies are instead intended to punish smokers by either: (1) making it more difficult for them to smoke outdoors; or (2) making it more difficult for them to find employment. The latter effect can be quite significant in communities in which a single hospital system is the major employer. If that hospital system refuses to consider applications from smokers, it truly does make it much more difficult for smokers to find employment. This is especially true with the job shortages we are facing today. The implications of this development for public health is that we are now using employment discrimination as a strategy for health promotion."
Similarly, I argued that: "At a national level, the tobacco control movement has waged a war on smokers, rather than on the tobacco industry and its most hazardous products."
I concluded with the hope that: "2012 will bring a re-examination of the public health practice of tobacco control and a return to the basic public health objectives that the movement is supposed to serve."
The year 2012 began with a feature article in USA Today about the issue of employment discrimination against smokers. The article discussed the growing trend of policies by which employers fail to hire smokers. Some of these policies apply not only to smokers, but to anyone using nicotine, whether in the form of cigarettes, smokeless tobacco, or even nicotine-containing medications designed to help smokers quit.
According to the article: "'These policies represent employment discrimination. It's a very dangerous precedent,'' says Michael Siegel, a professor at Boston University's School of Public Health. He says the restrictions punish smokers rather than helping them quit."
In perhaps a ray of hope, the American Lung Association appeared at least somewhat ambivalent about these policies: "Paul Billings of the American Lung Association says he's seen no data that prove nicotine-free hiring gets people to quit."
Last week came news from a new survey by the American Legacy Foundation, which reported that the social stigma associated with smoking has become so severe that "one-in-ten smokers (13%) in the United States did not disclose their smoking status to their health care providers (HCP), who are among the most important resources that a smoker could have in quitting successfully. Furthermore, social stigma around smoking may contribute to why smokers sometimes keep their smoking status a secret from their doctors."
This means that six million smokers fail to disclose their smoking status to their health care providers.
Dr. Cheryl Healton, president and CEO of the Foundation stated: "As an unintended result of higher prices of cigarettes, increased measures to ban smoking in public places, and create smoke-free workplaces, many smokers may feel marginalized and less compelled to discuss smoking with their physicians and other providers."
The Rest of the Story
I agree with Dr. Healton that the increased social stigma associated with smoking is a direct result of certain anti-smoking policies. However, I disagree that it is an "unintended" result of these policies. Instead, I believe that this result is precisely what many anti-smoking groups have intended.
If the goal were simply to prevent substantial exposure of the public to secondhand smoke, then why the need to ban smoking in an entire downtown area, or in a huge, wide-open park like New York City's Central Park? If the goal were simply to protect workers from secondhand smoke, then why the need to ban smokers from the workforce, even if they only smoke in the privacy of their own home? And why the need to deny employment to people who are trying to quit, albeit with the use of nicotine-containing devices like the nicotine patch or electronic cigarettes? Why the need to ban smoking on an entire college campus, rather than just indoors and in public areas where people congregate near the entrances to the buildings? Why the need to prevent smokers from adopting or fostering children, even if they agree not to smoke in the vicinity of their children? Why the desire to define smoking in the presence of children as a form of child abuse, and to treat it as such?
I would contend that the philosophy which supports each of the above policies is intended to stigmatize smoking. There is nothing "unintended" about it.
Importantly, I do not believe that all anti-smoking policies increase the stigma associated with smoking. I believe that certain policies are the chief culprit: namely, the kinds of policies discussed above, which directly target the smoker rather than the smoke.
And there is evidence to back up this contention. Policies intended to prevent tobacco smoke exposure in the workplace, such as smoke-free restaurant policies, do not appear to lead to a feeling of discrimination among smokers, while smoker-free hiring policies do.
A 2005 article published in the American Journal of Public Health asks tobacco control and public health practitioners to reconsider the use of stigmatization of smokers as a strategy to reduce tobacco use (see: Bayer R, Stuber J. Tobacco control, stigma and public health: Rethinking the relations).
The article notes that strategies used to combat tobacco use have, in some cases intentionally, stigmatized smokers in an effort to try to reduce smoking rates. For example: "The advocacy group Americans for Non-Smokers' Rights noted that tobacco control advocates had stumbled onto the best strategy for reducing tobacco consumption, 'encouraging society to view tobacco use as an undesirable and antisocial behavior.'"
Another example provided by Bayer and Stuber is the discriminatory and intrusive employment policies that have been discussed in recent months in The Rest of the Story: "Firms boldly announce that they will not employ and may even fire smokers because of the additional cost of their medical care, or because smoking does not project the 'image' they wish to present to the public."
For perhaps the first time in a major public health journal, these authors are questioning, on an ethical as well as utilitarian basis, whether the stigmatization of smokers is justified in public health. They note that efforts to reduce smoking by stigmatizing smokers "run counter to a revisionist orthodoxy that had emerged during the last years of the 20th century that asserts that stigmatization of those who are already vulnerable provides the context within which disease spreads, exacerbating morbidity and mortality by erecting barriers between caregivers, and those who are sick, and by imposing obstacles on those who would intervene to contain the spread of illness. In this view, it is the responsibility of public health officials to counteract stigmatization if they are to fulfill the mission to protect the communal health."
The authors note that the tendency of the tobacco control movement to "ignore without comment the overarching concerns raised in prior years about the relation between stigmatization and effective public health interventions. ... the moral question of how to balance the overall public health benefit that may be achieved by stigmatization against the suffering experienced by those who are tainted by 'spoiled identities' is virtually never addressed."
The authors suggest that the answer to this balancing question may lie with a careful analysis of "the nature and extent of stigma-associated burdens and on how the antitobacco movement deploys stigmatization as an instrument of social control. For example, policies and cultural standards that result in isolation and severe embarrassment are different from those that cause discomfort. Those that provoke a sense of social disease are not the same as those that mortify. Acts that seek to limit the contexts in which smoking is permitted are different from those that restrict the right to work, to access health or life insurance, or to reside in communities of one's choice."
While I believe that there are some advocates in the tobacco control movement who do not support smoker-free hiring policies, the tobacco control movement has made it difficult if not impossible for them to voice their opinions because it has sanctioned such behavior. Moreover, anti-smoking groups have conspired to hide internal dissent on smoker-free employment policies from public knowledge.
In 2006, 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 (Globalink). 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 is that there is a concerted effort in the tobacco control movement to promote policies that stigmatize smokers and to quell any dissent from those who disagree with this approach. The combination of these actions has led to a measurable negative impact on health care for smokers, in the form of a reluctance on the part of about six million smokers to disclose to their physicians that they smoke.