Newspaper Editorial Supports Smoking Bans in Homes; As Car Smoking Bans Spread, Concern Over Intrusion into the Home Should Jolt Anti-Smoking Groups

An editorial in yesterday's The Journal News (lower Hudson Valley, New York State) supports the idea of banning smoking in the home when children are present.

The editorial, written in response to the recent proliferation of laws banning smoking in cars with children present, supports those laws. But it goes further, stating that extending these bans into the home is also justified. Car smoking bans are seen as a good first step, but the ultimate step is clearly expressed as banning smoking in homes with children.

According to the editorial: "Starting today, residents of Bangor, Maine, can be stopped and ticketed for smoking in their vehicles if children are with them. Another case of a nanny state run amok? Not when the party gaining protection is kids - beneficiaries often unable to stick up for themselves.The Rockland County Board of Health wants the county to join the fledgling movement to ban smoking in motor vehicles when children under 18 are present. It seems a no-brainer to protect minors, for whom tobacco is off-limits anyway, from the damaging effects of second-hand smoke - especially as the kids sit in a car, often with little ventilation, as non-thinking adults puff away. In fact, it makes sense to protect all New York kids, not just Rockland's. ...

Second-hand smoke exposure precipitously raises kids' risk of diseases such as bronchitis, pneumonia and asthma. In children, these can kill - making second-hand smoke akin to child abuse. ...

While the home has always enjoyed special protection from government intrusion - police can't enter without a warrant or exigent circumstances - we see little justification for making the family room a sanctuary for those thoughtless enough to poison their kids with tobacco smoke. In any case, the family car is a fitting start."

A smoking ban in cars when children are present was enacted earlier this week in Bangor, Maine. Similar statewide bans are in place in Arkansas and Louisiana, and are currently under consideration in Connecticut, Maine, California, and New Jersey.

The Rest of the Story

The one good thing that can be said about this editorial is that at least it presents a consistent argument. Unlike the proponents of car smoking bans in Bangor and elsewhere, the editorial board is not just talking the talk about protecting children but failing to actually put its actions where its mouth is. The newspaper is taking a strong position in favor of protecting children from exposure to secondhand smoke, and that exposure does not start and end in the family car. The home is a more important source of exposure, as the duration of that exposure is much higher than in a car.

The problem is that the policy the newspaper is supporting represents an unwarranted intrusion into the private home. In an era when the government has apparently been wire-tapping private citizens, we need to draw a firm line to protect citizens from government intrusion into their homes -- particularly, when it comes to merely protecting citizens from an increased risk of disease.

Before going any further, I should make it clear that there are legitimate justifications for government intrusion into the private home. Specifically, there are two.

One is to protect people from immediate, severe, and direct harm. We do intrude into the private home to protect people from physical and sexual abuse. Children, in particular, need and deserve this protection.

But there is a difference between risk and harm, and it is critical for anti-smoking advocates to understand that distinction. Physical and sexual abuse results in direct, immediate, and severe harm to children. It is not merely a question of increasing the risk for some illness or disease. It is an issue of direct harm.

Once we start intruding into the private home to protect children from merely the increased risk of illness, we have crossed a line that should not be crossed. That would open the door to regulating all kinds of risks to which parents expose their children. That justification for intervening to protect kids from secondhand smoke would also justify laws that prohibit parents from taking their kids to fast food restaurants, serving them food with trans-fats, not forcing them to get sufficient physical activity, not putting sunscreen on their kids, allowing their kids to ride heelies, allowing their kids to drive, serving alcohol to their own kids, or using wood-burning stoves in the house when children are present.

The second justification for government intrusion into the home is to prevent the risk of immediate death from life-threatening emergencies, particularly fires. So we have requirements regarding fire safety -- such as requiring smoke detectors, electrical inspections, proper ventilation of wood-burning appliances, etc. These are deemed necessary because failure to take these precautions can lead to immediate death.

Such is not the case with secondhand smoke exposure.

What the Journal News does not appear to understand - and this is critical - is that secondhand smoke is not akin to child abuse because it usually does not involve harm; it merely involves increased risk of illness. Child abuse is behavior that immediately, directly, and severely harms children. Behaviors that merely put kids at increased risk of disease - such as feeding them fast food or exposing them to smoke from wood-burning stoves - do not represent child abuse.

These behaviors might be viewed as stupid, unfair, uncompassionate, and irresponsible, but they are not child abuse. I'm not saying that we should view them this way; I'm just pointing out that however anti-smoking advocates do view these behaviors, they are wrong in equating or comparing smoking around kids to abusing them.

It seems to me that there are two possibilities to explain the proliferation of proposals to ban smoking in cars with children, and both are equally troubling.

First, it could be that anti-smoking groups are just disturbed by the exposure of kids to smoke in cars (which they should be) and want to get rid of it, but they have no intention of promoting banning smoking in homes. If this is the case, then they are being inconsistent in their arguments. They are passing feel-good laws that do little to really protect kids from secondhand smoke exposure but allow them to think that (and say that) they are doing something for the kids. They are taking a troubling step by accepting that the government can interfere with parental autonomy and individual privacy by regulating parental behavior that merely puts their kids at increased risk of disease, but then failing to act to protect kids where the exposure actually causes disease: in the home. The sincerity of our desire to protect kids then really comes into question.

Second, it could be that anti-smoking groups are promoting smoking bans in cars merely as a stepping stone to home smoking bans. If that is the case, then the anti-smoking movement is at least consistent and sincere in its desire to protect kids, but it is willing to cross the line into regulating private behavior in the home to merely reduce the risk of illness. That is a dangerous concept. We don't want to go there.


(Thanks to JustTheFacts for the tip).

Bangor Car Smoking Ban Proponents Tout New Law As Placing Health of Kids Above Bad Habits of their Parents and Concerns for Civil Liberties

Proponents of Bangor's recently enacted ban on smoking in cars with children present are preparing to publicize the new law, and are touting its placement of the health of kids above the smoking habit of their parents and above concerns over erosion of civil liberties.

According to a Bangor Daily News article: "Thanks to an anonymously funded 10-day radio campaign that will begin this week, few area residents will be able to claim ignorance of a new citywide ban on smoking in vehicles when a child is present. ... According to Elinor Goldberg, executive director of the nonprofit Maine Children’s Alliance, an anonymous donor recently contributed $2,000 to pay for a radio campaign designed to alert people about the new ordinance. ... Goldberg acknowledged that many people object to the new ban as an erosion of civil liberties, but likened the initiative to measures that protect children against physical abuse at the hands of their parents. 'This isn’t about civil liberties at all,' she said. 'It’s about protecting children’s health.'"

"Larry Julius, market manager for Clear Channel Communications in Bangor, said two paid advertisements will start airing Friday, the day the smoking ban takes effect. ... 'I have been a supporter of this initiative from the beginning, and I am very proud to be part of a community where the health of its kids doesn’t take a back seat to the bad habits of their parents,' he said."

Supporters of a proposed car smoking ban in Rockland County, New York expressed similar arguments. According to an article in The Journal News: "Add automobiles to the growing list of places where smokers might soon be banned from lighting up.The Rockland County Board of Health adopted a resolution yesterday recommending that the county 'study the possibility of prohibiting smoking in automobiles when children under the age of 18 are present.' 'It makes a great deal of sense to prohibit smoking in cars,' said Dr. Jeffrey Oppenheim, a neurosurgeon and the member of the board who proposed the ban. 'Children don't have a choice when someone lights a cigarette in a car with closed windows.'"

The Campaign for Tobacco-Free Kids expressed support for the proposed measure, stating (according to the article): "The evidence that secondhand smoke is harmful to children is so overwhelming that it trumps all other arguments."

The Rest of the Story

As well-intentioned as the proponents of these smoking bans might be, I'm afraid that their arguments leave a lot to be desired.

A law that bans smoking in cars with children present but allows smoking in homes with children present does not place the health of children above the smoking habit of their parents, nor does it put children's health above the protection of civil liberties.

If the Maine Children's Alliance were correct that: "This isn’t about civil liberties at all. It’s about protecting children’s health," then the Bangor City Council would have (and should have) banned smoking in the presence of children - period. Banning smoking in the very limited time that children are traveling in a car, but allowing it for the hours upon hours that children are in the home makes no public health sense at all, and it certainly doesn't cast the issue as not being about civil liberties.

If Bangor were truly "a community where the health of its kids doesn’t take a back seat to the bad habits of their parents," then it would have (and should have) banned smoking in homes when children are present.

Bangor clearly did let "the health of its kids take a back seat to the bad habits of their parents."

If the evidence that secondhand smoke is harmful to children "trumps all other arguments," then why isn't the Campaign for Tobacco-Free Kids calling for legislation that bans smoking around children - in the home as well as in cars?

I hate to have to say this, but this is really crap. The evidence that secondhand smoke is harmful to children does not trump all other arguments. If it did, then we should simply ban all smoking in the presence of children. Any organization that truly believes that the evidence that secondhand smoke is harmful to kids trumps all other arguments but does not call on smoking bans in the home with children is talking out of both sides of its mouth (something that is not new for the Campaign for Tobacco-Free Kids).

Obviously, I am not arguing here that smoking should be banned in homes with children. It shouldn't. What I am pointing out is that the arguments being used to support car smoking bans to protect children's health are faulty. It is a lot of rhetoric, but very little substance.

I understand that there are anti-smoking groups which support car smoking bans in order to protect children from secondhand smoke exposure in cars. They are entitled to support such proposals. But don't give me all this crap about how such policies put the health of children above all other arguments. They don't. If you really want to talk that talk, then put up or shut up. Put up by calling on smoking bans in the home. Otherwise, cut out all the rhetoric about not letting the health of kids take a back seat to the habits of their parents.

Of course you're letting the health of kids take a back seat to the habits of their parents. Of course you're letting other arguments take precedence over the health effects of secondhand smoke on kids. Of course you're putting civil liberties above protection of children's health. You're doing all of these things because you apparently recognize that banning smoking in the home is not a justified intrusion into parental autonomy and individual freedom and privacy.

I, of course, would argue that the same concerns about intruding into parental autonomy and individual freedom and privacy hold for the car as well as the home. Others may somehow disagree and argue that there is a difference between a private car and a private home. I don't see the difference, but someone could advance the argument. But don't try to make people think that you are putting kids' health above all other concerns. You're not. In fact, you're ignoring the larger and more important concern - smoking in the home - and merely feeling good about yourselves by addressing a concern - smoking in cars - that creates merely transient exposure. The exposure in homes is far greater in duration and therefore far more significant than exposure in cars.

If you're not willing to walk the walk, then please don't talk the talk.

Anti-Smoking Advocates' Arguments Deteriorate After Lack of Health Basis for Broad Outdoor Smoking Bans is Exposed

After Sunday's InsideBayArea.com and Contra Costa Times articles exposed the weakness of anti-smoking groups' argument that complete outdoor smoking bans are necessary because even a brief exposure to secondhand smoke can cause heart disease or cancer, it appears that their arguments in support of Calabasas and Belmont-type (complete) outdoor smoking bans are rapidly deteriorating.

On an international list-serve discussion forum regarding secondhand smoke, one advocate argued that despite the lack of evidence that complete outdoor smoking bans are necessary to avert a substantial public health hazard, they are still justified because government also routinely bans outdoor behavior that is considered "intrusive, corruptive of minors, or offensive."

The advocate wrote: "Some examples of these banned or heavily restricted activities include touching another person without their permission, nudity, overt sex, urinating, defecating, spitting, playing loud music, drinking alcohol, smoking marijuana, injecting heroin, snorting cocaine, etc."

Another advocate argued that these complete outdoor smoking bans are justified because outdoor levels of smoke can be quite high.

Another advocate addressed neither the science issue nor the offensiveness of public smoking issue, resorting instead to the old ad hominem attack: "I suggest the only credibility we are supposed to have lost is caused by Siegel and Chapman." [Dr. Simon Chapman was quoted in the article as also opposing most broad outdoor smoking bans because they are not justified based on scientific evidence of a severe and unavoidable public health hazard.]

The title of this particular discussion forum message had nothing to do with the substantive topic at hand. Instead, it was simply: "Michael Siegel, again."

The Rest of the Story

Let's take these one at a time.

Argument #1: Completely banning smoking outdoors is justified because like public urination, defecation, nudity, sex, heroin injection, and cocaine snorting, it is intrusive, corrupting of minors, and/or offensive.

One could certainly argue that outdoor smoking is intrusive; however, in most situations, the smoke can be easily avoided. At worst, the intrusion is minimal, with only a few seconds of exposure necessary to get out of the way or past the smoker. Absent the health effects, the intrusiveness argument could also be made about wearing perfume or having bad body odor. Is this where we really want to go? Absent any substantial public health hazard, I do not see how banning smoking completely is necessary, narrowly enough tailored an intervention, or justified.

The argument that smoking needs to be banned because it is corrupting of minors or offensive hardly deserves comment. Smoking is a health hazard - plain and simple. It is not, and should not be considered an offensive public behavior in the absence of the creation of a significant health hazard.

The advocate is correct that it is more than simply protection of the public's health and safety which justifies the use of the state's police power to ban certain outdoor behavior. Another concern is protection of the public morals. Banning outdoor sex, nudity, defecation, urination, and illicit drug use all fit under this category of measures deemed necessary to protect public morals.

By making this analogy, the advocate is suggesting that public smoking fits into the same category of behaviors that are morally offensive.

And to be honest, that's what I really think this all comes down to. When you strip away the bogus health arguments (that all it takes is a brief exposure for someone to keel over from a heart attack or to wind up getting heart disease or cancer), what you're left with is the argument that public smoking is morally offensive and that the state's police power needs to be invoked to protect the public morals.

By even comparing public smoking to outdoor urination, sex, nudity, and the like, the advocates and groups offering this argument are, I think, exposing exactly how it is that they perceive outdoor smoking. It is offensive to them and that's apparently the primary reason why banning it completely is justified.

Argument #2: Levels of tobacco smoke outdoors can be very high.

While it is true that outdoor levels of secondhand smoke can potentially be high under certain conditions, one must remember that exposure is dependent upon two factors, not one. Exposure is dependent upon: (1) the level [concentration] of the smoke; and (2) the duration of exposure to the smoke.

No matter how high the concentration of smoke around a group of smokers might be, if it is an outdoor area that is open and which people can move freely about, they are able to avoid prolonged exposure and the dose they receive will not be high.

The advocates advancing this argument are creating a straw man argument: they are arguing that the potential for smoke to be heavily concentrated outdoors in some conditions justifies banning smoking under all conditions. But that's not the issue at hand.

Neither I nor Dr. Chapman has argued that outdoor smoking should not be regulated in environments in which people are fixed and cannot move freely about to avoid the smoke exposure. When I'm watching the Red Sox lose in Fenway Park, of course I think it is justified to ban smoking in the Park. If I'm sitting in my seat, there's no way for me to avoid the smoke. I'm in a fixed, assigned seat and there's nowhere to go.

But if I'm walking to my car and someone is smoking in the parking lot, I can easily avoid any significant exposure to the smoke.

Banning smoking in Fenway Park is justified. But banning it in all sidewalks, streets, parking lots, and everywhere else outdoors is not. And that's what this discussion is about. That's the policy that Calabasas has enacted and which Belmont has proposed. That was the impetus for the newspaper article and that is the criticism to which my comments relate.

Argument #3: Dr. Siegel is at it again. He's hurting our credibility.

This is probably the strongest of the three arguments, because at least it's half right. Yes, I am at it again. And I will continue to be at it as long as I feel the need to speak out for what I believe, to tell the truth where I think it needs to be told, to say the difficult things that need to be said to preserve (if it's not too late) the integrity of the tobacco control movement, and to demand that we are justified in our calls for public policy changes.

As far as hurting the credibility of the movement, I'll let the public be the judge of that. But I would submit that someone who is willing to point out an absurd claim when he sees one (e.g., 30 minutes of secondhand smoke increases your risk of heart disease, as the Surgeon General has implied) has a lot more credibility than someone who is so biased that he or she can only see one side of any issue and for whom the anti-smoking groups can never be wrong, no matter how absurd the claims may be.

It's interesting, because it has become clear to me that the ad hominem attacks against me always heat up whenever it is that I make my strongest arguments. It's as if advocates are able to sense when what I'm arguing is really striking a chord with the public and they reflexively swing into attack mode, unable to respond effectively in a substantive manner.

Thus, the issue becomes not whether or not broad outdoor smoking bans are justified, but Michael Siegel and his antics. That tobacco industry stooge. That right-to-smoke advocate who has been duped by tobacco industry propaganda. That tobacco sympathizer who, once upon a time, did some very good work.

CDC Defends Surgeon General's Statement that Brief Exposure to Secondhand Smoke Causes Lung Cancer

Rather than correcting the misrepresentation of science by the Surgeon General in his press release announcing the publication of the 2006 report on secondhand smoke, the Centers for Disease Control and Prevention (CDC) is apparently defending the Surgeon General's statement.

Here's the story:

In June 2006, the U.S. Surgeon General released a comprehensive report on the health effects of secondhand smoke which concluded that chronic exposure to tobacco smoke causes heart disease and lung cancer in nonsmokers.

However, in the press release accompanying the report, the Surgeon General claimed that: "Even brief exposure to secondhand smoke has immediate adverse effects on the cardiovascular system and increases risk for heart disease and lung cancer, the report says."

On June 28, I wrote on this blog that the Surgeon General had misrepresented the findings of the report, since the report mentioned nothing about brief secondhand smoke exposure causing heart disease and lung cancer. Further, I noted that the statement in the press release flies in the face of common medical sense, since we know that heart disease takes many years of exposure to develop, even in an active smoker. So how could a brief exposure to secondhand smoke cause heart disease in a nonsmoker?

Moreover, there is absolutely no scientific evidence that a brief exposure to secondhand smoke causes lung cancer in nonsmokers.

Sunday's feature article run by InsideBayArea.com highlighted my concerns: "Siegel's greatest concern with the tobacco control movement today is what he views as exaggerated assertions advanced by major public health organizations, including the U.S. Surgeon General's office, that fleeting exposure to secondhand smoke poses a serious public health threat. In June, the Surgeon General released an updated report on the dangers of secondhand smoke. A news release accompanying the report warned that "even brief exposure to secondhand smoke has immediate adverse effects" by increasing the odds of developing heart disease and lung cancer."

When confronted with my criticism of the Surgeon General's statement, the CDC apparently defended the statement: "The CDC's Pechacek also explained the reason for the Surgeon General's warning that even brief exposure could trigger cancer. 'There is some risk that even a very small amount can damage a cell," he said, setting off a chain reaction that causes cancer.'"

The CDC also apparently refused to explain what it meant by "brief" exposure: "The word "brief" is also left up to interpretation. 'We can't quantify what is 'brief,'' said Pechacek, who declined to state how long an interval qualifies as 'brief.'"

The Rest of the Story

This is a very important story, because to me, it is the first evidence that the Surgeon General's statement that brief secondhand smoke exposure causes heart disease and lung cancer was not merely a mistake, but was a conscious and intentional misrepresentation of the findings of the Surgeon General's report.

It truly appears that CDC is indeed defending the statement that brief secondhand smoke exposure causes lung cancer in nonsmokers.

And they are doing it based on the possibility that a small amount of exposure could potentially damage a single cell.

By this reasoning, any exposure to any carcinogen could be said to increase the risk of cancer. By this reasoning, the CDC should also be warning the public that:

• A single chest X-ray causes cancer.
• Being in the sun for thirty seconds causes cancer.
• Breathing in diesel fumes for ten seconds causes cancer.
• Eating peanut butter causes cancer.
• Eating a single char-broiled burger causes cancer.
• Drinking a sip of chlorinated water causes cancer.

In fact, just the process of living every day could be said to cause cancer, since there is always damage being done to our cells that could potentially trigger cancer. The body has defense mechanisms that repair this damage constantly. This is the reason why it takes more than a single exposure to cause cancer. The exposure has to overwhelm the body's ability to repair the damage.

Using the CDC's reasoning here, all of its statements about the causation of cancer would become meaningless. Once you are willing to state that a single exposure to a carcinogen that could potentially damage one cell is enough to warrant a public statement that the exposure causes cancer, then all of your statements about carcinogenic exposures become meaningless. In fact, it really undermines your statements about carcinogenic exposures that truly are significant.

Moreover, CDC was apparently unwilling to define what it meant by "brief." Well if you can't define what you meant, then you shouldn't be making such a claim.

But most importantly, there is simply no evidence to support the Surgeon General's claim. There is no evidence that a brief exposure to secondhand smoke can cause lung cancer in a nonsmoker.

If you're going to make such a statement to the public, you have to be able to back it up with some evidence. And here, there simply is no evidence to support the claim.

In some ways, the claim could be a dangerous one, undermining the Surgeon General's warning about exposure to secondhand smoke. If people truly believe that even a brief exposure to secondhand smoke causes lung cancer, then why should they try to avoid or minimize their exposure to secondhand smoke? All of us have already been exposed to some secondhand smoke. If the cancer process has already been set in motion, then what point is there to minimize our exposure?

And the message to smokers is potentially more damaging. What incentive is there to quit smoking if a person could successfully quit, only to breathe in secondhand smoke for a few minutes and wind up with cancer anyway?

I would have felt much better if the CDC had simply acknowledged that the statement made by the Surgeon General was a mistake and that the truth is that it takes some degree of chronic exposure to secondhand smoke to develop heart disease or lung cancer. That would have been the responsible thing to do.

And it would have made it clear that the statement was simply a mistake.

But instead, we are left with the impression that the statement was not a mistake, but was an intentional expression of what the CDC believes is an adequately-supported scientific fact: that brief exposure to secondhand smoke does indeed cause heart disease and lung cancer. But since we know that it takes at least 20 years for even active smokers to develop heart disease, it is pretty clear that this statement is false.

Thus, it now becomes hard to avoid the conclusion that the Surgeon General is intentionally misrepresenting the findings of his own report to suggest to the public that brief exposure causes heart disease and lung cancer, when the report itself concludes, quite unmistakably, that chronic exposure to secondhand smoke causes heart disease and lung cancer.

The implications of this misrepresentation of science and the failure to correct a statement that is not only false, but absurd, on its face, is that not only is the credibility of the anti-smoking movement in question, but now the credibility of the Office of the Surgeon General, and even the CDC itself, comes into question.

Look - I've worked directly in the Office on Smoking and Health at CDC. I worked there for two years, and was partly responsible for many of the scientific statements that our office made. So I am the first to acknowledge that it is difficult work and that sometimes, you just make a mistake.

That's fine - I'm willing to give the Surgeon General's office and the CDC the complete benefit of the doubt and simply accept that the statement that brief secondhand smoke exposure can cause heart disease and lung cancer was merely an oversight.

The problem is that now - when confronted with the statement and given the opportunity to correct it - the CDC has apparently chosen instead to defend it. That is a problem, because now it becomes, at least in my view, a conscious and deliberate act not to correct the statement when you have the perfect opportunity to do so, but instead, are reported to be defending the statement.

I have certainly made my share of blunders. One of them was right here on this blog, when I made the false assumption that the failure of a journal article to report a conflict of interest of the authors was a fault of the authors. It turns out that the journal made a mistake in not printing the conflict of interest disclosure that was made. I immediately acknowledged this, corrected it, and apologized. And if anyone points out anything I've written that is in error, I'm committed to correcting it.

The reason is not only that I want to be accurate, but because my reputation as a credible source of information, analysis, and commentary on tobacco control issues is at stake. If, in one situation, I report errant information and don't correct it, then my readers will never really know whether what I'm reporting is accurate or not.

Well the same thing holds with our public health agencies. It may not seem like much to make one inaccurate statement in a press release, but if the agency loses its credibility as an accurate and responsible purveyor of scientific and health-related information, then its effectiveness in communicating important information and warnings to the public may be shot.

At some point, the crisis of credibility that I've been writing about in the tobacco control movement is going to cross the line over into public health itself. This is the first example we've seen of this, because although the office that handles much of the Surgeon General's communications is specifically devoted to tobacco control issues, it is also a part of the larger CDC, and thus is part of the public health establishment in general.

Isn't our credibility worth anything? Is it really worth risking everything just to avoid having to acknowledge that we made a mistake? Why do we in tobacco control seem physically unable to simply admit that we made a mistake? Why do we insist on defending claims that, on their face, are absurd?

I wish I understood the answers to these questions. Any help will be greatly appreciated.

Lead Story in Bay Area Sunday Newspapers Features Anti-Smoking Movement's Push for Outdoor Smoking Bans and Questions the Science Behind Them

The lead story in Sunday's edition of a number of (San Francisco) Bay Area newspapers features a discussion of the anti-smoking movement's recent push for complete outdoor smoking bans and questions the science being used to justify these policies.

The story, written by Suzanne Bohan, was published on InsideBayArea.com, and appeared in the newspapers that are part of this conglomerate: The Oakland Tribune, Marin Independent Journal, San Mateo County Times, The Argus, The Daily Review, the Tri-Valley Herald, and the Alameda Times-Star.

The article highlights my own career in smoke-free workplace advocacy, noting that I have been a strong supporter and advocate for smoke-free workplaces, including bars and restaurants, but have argued that broad outdoor smoking bans go too far, risking the loss of credibility and effectiveness of the tobacco control movement by pushing for policies that are not driven by science documenting a compelling public health justification:

"IN THE early 1990s, Dr. Michael Siegel began leading pioneering efforts to ban smoking in workplaces to protect the health of nonsmokers. Siegel, who got his start in the anti-smoking cause while earning his master's degree at University of California, Berkeley, has written dozens of scientific articles on the dangers of secondhand smoke. His testimony in court and at countless city council meetings also helped push public policy toward tighter restrictions on smoking.

But now Siegel is speaking out against the movement he helped create. Why? Today's anti-smoking crusaders, he says, have lost their moorings in science by advocating smoking bans in the last refuge for smokers — the great outdoors. 'I've been working in this field for 21 years,' said Siegel, who earned an M.D. from Yale University and a master's degree in public health from UC Berkeley. 'The goal was to get rid of smoking in the workplace. I never understood that the goal was to get rid of smoking so that no one even gets a whiff of smoke.' 'It's a grass-roots social movement that's been so successful that it doesn't know where to stop,' Siegel continued. 'It's getting to the point where we're trying to protect people from something that's not a public health hazard.' At risk, he and other like-minded tobacco control advocates assert, is not only the credibility of public health officials, but the undermining of a freedom prized in democracies — do as you wish so long as you don't harm others."

The article cites the recently enacted smoking ban in Calabasas - where smoking is prohibited almost everywhere outdoors - and the proposed smoking ban in Belmont - where smoking is to be prohibited everywhere outdoors - as two examples of the anti-smoking movement's push to ban smoking in the great outdoors.

I am quoted as contesting the science being disseminated by anti-smoking groups, including the Surgeon General's office, that even very brief exposure to secondhand smoke can cause cardiovascular disease and cancer. "'It takes many years for these chronic diseases to develop,' Siegel said in the article. 'We're really risking our credibility (as public health professionals) by putting out rather absurd claims that you can be exposed briefly to secondhand smoke and come down with heart disease or cancer.'"

Countering my argument that these broad outdoor smoking bans are going too far were two anti-smoking researchers.

The first counterpoint came from Dr. Stan Glantz, a professor of medicine at the UCSF School of Medicine. According to the article: "Siegel was once a student of Glantz's, but the two men are now at loggerheads over the direction of the anti-smoking movement. 'He did some very good work, once upon a time,' Glantz said of Siegel."

"Glantz insists there is a health effect worth worrying about with exposure to cigarette smoke outdoors, particularly for those with chronic heart disease. 'It's going to be a very small number, but there is some risk,' Glantz said. 'But that's true of a lot of environmental toxics, like diesel exhaust.' ... Glantz, for example, said even five minutes of breathing tobacco smoke changes blood chemistry and blood vessel function enough to increase the risk of a heart attack in people with severe heart disease. 'So there is some risk associated with brief exposures under some outdoor circumstances,' Glantz said. 'No one has quantified the magnitude of the risk.' ... Nonetheless, even small odds justify legislative action against outdoor smoking, Glantz said. "If you can't be assured the risk is zero, you should act," he said."

The second counterpoint came from Dr. Terry Pechacek of the Centers for Disease Control and Prevention's Office on Smoking and Health (where I worked from 1993-1995): "'We don't have sufficient data to evaluate levels of exposure in outdoor settings,' Pechacek said. ... The CDC's Pechacek also explained the reason for the Surgeon General's warning that even brief exposure could trigger cancer. 'There is some risk that even a very small amount can damage a cell,' he said, setting off a chain reaction that causes cancer.'"

The Rest of the Story

Once upon a time...

Apparently, I once was a competent scientist, researcher, and epidemiologist who did some very good work, but now, suddenly, I am incompetent.

Once upon a time there was a tavern
Where we used to raise a glass or two
Remember how we laughed away hours
And dreamed of all the great things we would do.
(lyric credit to Gene Raskin)

Odd, isn't it? Usually, as we get more experienced and knowledgeable in our careers, we get better at we do, not worse. Apparently, my very good work came when I was merely a student. Having subsequently completed an epidemiology fellowship at CDC and worked for 11 years as a tobacco control researcher at Boston University, progressing to become a full professor, I have now lost my ability to interpret scientific and medical literature.

Suddenly,
I'm not half the man I used to be
There's a shadow hanging over me
Oh yesterday came suddenly.
(lyric credit to John Lennon and Paul McCartney)

Of course, what it really looks like is that when my review of the literature produced a conclusion favorable to the pre-ordained agenda of the anti-smoking movement, it was considered to be very good work, but now that my (even more rigorous and informed) review of the literature produced a conclusion that anti-smoking groups are exaggerating their public claims, my work is no longer any good.

You've lost that lovin' feelin'
Woh oh that lovin' feelin'
You've lost that lovin' feelin'
Now it's gone, gone, gone.
(lyric credit to Phil Spector, Barry Mann, and Cynthia Weil)

As I've learned, in the tobacco control movement, when they talk about the quality of your work, what they are really talking about is the perceived favorability of your conclusions to the established anti-smoking dogma - not the scientific quality of your work, which for me, has obviously improved with experience, knowledge, and expertise.

Once I could see, once I could feel
Now I am numb, I've become unreal
I walk the night, without a goal
Stripped of my heart, my soul.
(lyric credit to Carl Sigman [original French lyrics by P. Delaoe])

Actually, there really doesn't seem to be any scientific disagreement at all among the tobacco control researchers who were interviewed for this article:

I believe there is not sufficient scientific evidence to conclude that there is any substantial public health risk posed by allowing smoking in most open outdoor environments where people can move freely about.

Dr. Glantz believes that the risk is very small, just like outdoor exposure to diesel exhaust, and that no one has quantified the magnitude of this small risk.

Dr. Pechacek believes that we don't have sufficient data to evaluate levels of exposure in outdoor settings, so there is no documentation of any serious public health threat.

So if there is no disagreement about the science, then why are we "at loggerheads?"

The answer appears to be, at least in part, our beliefs about the levels of risk that justify public health legislation to protect people from environmental hazards. Drs. Glantz and Pechacek appear to be arguing that any risk, no matter how small, is sufficient to justify legislated bans on a behavior. Even brief exposure to secondhand smoke might damage a cell, leading to cancer, so we apparently need to eliminate this possibility altogether. There is no risk-free level of exposure, so we need to completely eliminate exposure in order to eliminate risk.

On the other hand, I seem to have a higher threshold for invoking government legislative intervention. I would like to see a substantial level of risk before I advocate for coercive policies as a public health intervention. I don't believe that we necessarily have to reduce all environmental health risks to zero.

The answer also appears to be, at least in part, our beliefs about the levels of scientific evidence needed in order to justify legislated bans. Drs. Glantz and Pechacek appear to believe that legislated bans are justified even in the absence of scientific evidence that there is a substantial public health problem.

I, on the other hand, believe that we need to have solid scientific documentation of a substantial public health problem before we ask the government to intervene coercively to regulate the hazard.

I am not sure about this, but possibly another reason for being "at loggerheads" is the possibility that other anti-smoking advocates are not willing to criticize tobacco control groups for making misleading or inaccurate statements, (or to even admit that is possible?). Frankly, this is the only reason I can think of to explain the defensive posture of these researchers, rather than their simply admitting that yes - anti-smoking groups have been misleading the public by suggesting that brief secondhand smoke exposure can lead to heart disease.

I'm glad that this issue and the scientific and policy discussion has been prominently brought to the public's attention. Ultimately, it is the public who will serve as the final judge of whether, in its zeal to eliminate any possible risk of exposure to secondhand smoke outdoors, the anti-smoking movement is going too far, whether our claims about the chronic health hazards of merely brief, acute exposure to secondhand smoke are exaggerated, and whether the current state of the tobacco control movement is such that we can retain our credibility and our reputation as being a movement motivated by science and possessing some good sense and reason.

IN MY VIEW: It's Time to Stop Balancing Budgets on the Backs of Smokers

In my earlier post today, I cautioned against a hasty acceptance of the Iowa legislative leadership's proposal to provide universal health care coverage to Iowans through revenues generated by an increased cigarette tax on the grounds that it would make health care coverage dependent upon high levels of continued cigarette consumption. Here, I argue that the proposal is unfair because it balances the state budget on the backs of smokers.

What anti-smoking advocates need to realize is that when a cigarette tax increase to generate revenues to fund government programs, it is smokers who are paying for those programs. Even if some smokers choose to quit or cut down on the amount they smoke due to the tax, other smokers will be the ones who shoulder the burden of paying for those programs. This is unavoidable.

It is also true that in general, the heaviest smokers (the ones who will pay for the government programs) are among the poorer citizens. They are the individuals who can least afford the added burden of paying for these government programs.

If one were deciding the fairest way to allocate the financial burden of paying for a new government program, would it not be most fair to put that burden on those (individuals and companies) who can most afford to pay for it, rather than the opposite?

Anti-smoking advocates may argue that the tax is actually benefiting smokers because it causes many of them to quit smoking or at least to reduce the number of cigarettes that they smoke. While this is true, one cannot escape the fact that many smokers will not quit, and it is these smokers who will pay for the programs for the benefit of everyone else.

It seems to me that if you are going to use taxes to fund specific new programs, the benefits of the tax should accrue, at least in part, to those who are paying it.

For example, if we want to widen the Mass Pike to decrease commuting time and we decide to obtain the needed revenue by increasing tolls on the Pike, that seems fair because the people who are paying those tolls are precisely the ones who stand to benefit from the reduction of Pike traveling time (this is, by the way, why you won't hear me complaining about the recent toll increases - sure I'm paying for it, but I'm also benefiting from it).

Providing universal health care coverage for all Iowans benefits all residents who don't currently have health insurance. However, the majority of those people do not smoke. So the only ones paying for the program will be smokers; yet, the majority of those benefiting from the program will be nonsmokers. This seems inherently unfair.

One could argue that smokers do benefit from the tax increase because it helps them to quit smoking. But if they quit, they will not be paying the tax. The burden of the tax will accrue to those who do not necessarily benefit from it.

It would be one thing if the tax were to be used specifically for programs that benefit smokers - such as prevention and cessation programs and medical care costs for smokers. I support the idea of cigarette tax increases when the revenue is used specifically for the prevention or treatment of smoking-related illnesses. Because in those situations, the people bearing the tax burden are precisely those to whom the benefits accrue.

But when the revenue is being spent for ancillary purposes -- especially for programs that the government should be funding anyway -- then the tax is inherently unfair.

What troubles me is that anti-smoking groups seem to have knee-jerk support for any cigarette tax increase, without even considering the fairness of the specific proposal and the distribution of the burden and benefits of the tax increase.

It needs to be recognized that principles of fairness, equity, and social justice are central principles of public health practice. Contrary to what many tobacco control practitioners seem to believe, public health is not simply about improving the public's health. It is about improving the public's health in a way that is consistent with equity and fairness, and in a way that advances, rather than impedes, the provision of social justice to all citizens.

From what I can see of the Iowa cigarette tax proposal so far (it is still in the draft stage and there is nothing on paper to review yet), it appears to be an unfair policy that will pay for a new government program that would otherwise throw the budget out of whack by taxing the poorer citizens of the state, rather than those who can most afford to pay for the program. I do think it is time to stop balancing state budgets on the backs of smokers.

Iowa Legislative Leaders Look to Cigarette Tax to Provide Revenues for Universal Health Care Coverage

Iowa Democrats on Wednesday announced a plan to provide health care coverage to the poor by raising the state's cigarette tax by $1.00 per pack. This initiative is estimated to raise $134 million, half of which would be used to "plug the gaps in current health care programs for the elderly and poor, such as Medicaid and free clinics," according to an article in the Charles City Press.

According to the article: "Democrats unveiled a plan Wednesday that would offer universal health coverage, with funding coming from a $1 per pack increase in the state'’s cigarette tax. 'We cannot reach universal health care without a large infusion of public dollars,' said Sen. Jack Hatch, D-Des Moines. ... Under the plan, the cigarette tax increase would be approved this year, raising about $134 million. About half of that money would plug the gaps in current health care programs for the elderly and poor, such as Medicaid and free clinics. The state currently offers health coverage to the children of the working poor, and the measure unveiled Wednesday would expand that program to cover their parents. At the same time, a special commission would be named to design a plan to offer health care to the roughly 250,000 Iowans who don'’t have coverage. ... 'The Democrats have campaigned on universal health care for 25 years,' Foege said. 'With a Democratic Legislature and a Democratic governor, there'’s no better opportunity to cover every Iowan.'"’

The Rest of the Story

Not so hasty on this one.

At first blush, the idea of using cigarette tax revenues to fund universal health care coverage may sound like a great one. A cigarette tax increase would reduce cigarette consumption and at the same time provide revenue that would increase health care access for Iowans.

However, there is a major problem with this proposal. By tying health care coverage for Iowa residents to cigarette tax revenues, lawmakers would essentially be tying health care coverage to continued smoking by Iowans. In other words, the state would become dependent upon high levels of cigarette consumption in order to be able to provide health care to its citizenry. This is a potentially nasty situation that could remove incentives to reduce smoking in the state as well as threaten the ability of state residents to obtain health care if smoking does decrease.

The very idea makes me cringe. It would not be a good feeling to know that the critical thing allowing for universal health care coverage of Iowans is high smoking rates by their fellow Iowans. It's kind of like shooting yourself in your right foot to save your left one. While you'll be improving health care access, you'll be doing so at the expense of maintaining high levels of smoking and therefore high rates of smoking-related disease. It may seem like an attractive short-term fix, but in the long run, it creates a dependence of the health care system on smokers. This is absolutely the last thing in the world that you would want to do!

Perhaps the Iowa legislature should start putting up signs that say: "Support universal health care coverage. Smoke heavily."

Or how about: "Help your fellow Iowans obtain access to health care. Buy a carton of Marlboros."

Or this T-shirt for Iowa smokers to wear: "I support universal health care coverage. I smoke."

And here's one to think about: "The health of Iowa's poor depends on cigarette sales. Please do your part. Buy by the carton."

Try this one: "Step up to the plate for the poor. Light up early and often."

Don't get me wrong. The idea of universal health care coverage is a great one, and I support it. But you need a stable source of revenue, and preferably, not one that is dependent upon a product that endangers health and therefore relies upon disease in order to garner that revenue.

This is not a perspective that you're going to hear from almost any other tobacco control practitioner, and certainly not from any anti-smoking groups. But it's one that I think needs to be considered. And that's why we have The Rest of the Story.

BMJ Article Urges that Smokers Be Denied Elective Surgery

An article in the current issue of BMJ argues that smokers should be refused elective surgery unless they quit smoking for at least one month because smoking impairs wound healing, increases the risk of infection, and imposes greater health care costs on a limited health care system.

Dr. Matthew J. Peters, a respiratory physician from Sydney, Australia, argues that: "Smoking up to the time of any surgery increases cardiac and pulmonary complications, impairs tissue healing, and is associated with more infections and other complications at the surgical site. These adverse effects compromise the intended procedural outcomes and increase the costs of care. Therefore, as long as everything is done to help patients to stop smoking, it is both responsible and ethical to implement a policy that those unwilling or unable to stop should have low priority for, or be excluded from, certain elective surgical procedures. Such a policy should be limited to procedures where the evidence of harm is strongest. These include plastic and reconstructive surgery and some orthopaedic surgery. ...

Increased use of hospital beds and associated costs mean less opportunity to treat other patients. Based on these data, five non-smokers could be operated on for the cost and bed use of four smokers and the non-smokers' surgical outcomes would be better. A well informed smoker, unwilling or unable to quit, might assume an increased risk for himself, but the decision is not his alone when it can indirectly affect others. Then, the community must involve itself. With surgery that is done for purely cosmetic purposes, the increase in the risk and consequences of wound infection or fat necrosis from smoking is unacceptable and surgery is illogical. In reconstructive surgery, whether breast reconstruction after mastectomy or as part of head and neck cancer surgery, smoking substantially increases the risk of wound infection, flap necrosis, and fat necrosis. If a patient wants breast reconstruction at the time of mastectomy, the development of wound infection or flap necrosis will delay adjuvant chemotherapy or radiotherapy. Therefore, unless reconstruction is required as part of essential surgery that cannot be delayed, it is good policy not to offer reconstruction until the patient has stopped smoking."

In a counterpoint response, Professor Leonard Glantz from my own Boston University School of Public Health argues that such a policy is overtly disriminatory, violates the most basic tenets of medicine, and would greatly distort the doctor-patient relationship. He counters the cost-effectiveness argument by noting that the same reasoning being used to support denying smokers surgery could equally be used to deny surgery to people who are obese or do not exercise.

Professor Glantz concludes: "Discriminating against smokers has become an acceptable norm. Indeed, at least one group of authors who believe smokers should be refused surgery blithely admits that it is "overtly discriminatory." The suggestion that we should deprive smokers of surgery indicates that the medical and public health communities have created an underclass of people against whom discrimination is not only tolerated but encouraged. When the World Health Organization announced that it would no longer employ anyone who smokes, public health and medical communities did not respond to this act of blatant bigotry. Similarly, it is shameful for doctors to be willing to treat everybody but smokers in a society that is supposed to be pluralistic and tolerant. Depriving smokers of surgery that would clearly enhance their wellbeing is not just wrong - —it is mean."

The Rest of the Story

It is disturbing to me that we have reached a point where the question of denying elective surgery to smokers would even be debated prominently in a premiere medical journal. The fact that this is even a consideration worthy of public debate in the medical community is quite troubling.

For the fourth straight day since I have returned from winter vacation, the most over-riding and striking aspect of this debate is the singling out of smoking as being the one behavior over which society should assert control in order to reduce health risks.

Could it not be equally well argued that patients who are obese should be required to lose weight before undergoing orthopedic surgery? Or that patients who do not exercise should be forced to start working out in the health club prior to surgery? There is convincing evidence that obesity impairs wound healing and that both obesity and lack of exercise are major impediments to recovery from surgery.

Refusing surgery to the fat and sedentary would save a tremendous amount of health care dollars and would greatly help to relieve the waiting line for elective surgeries for those who are "responsible" enough to control their weight and get enough exercise.

But we are not talking about denying elective surgery to fat people or those who fail to exercise. We are only talking about denying surgery to smokers. As Professor Glantz astutely points out: "The suggestion that we should deprive smokers of surgery indicates that the medical and public health communities have created an underclass of people against whom discrimination is not only tolerated but encouraged."

Professor Glantz' point about the distortion of the physician-patient relationship is also well-taken. Implementing the policy that Dr. Peters advocates would inevitably lead to smokers being afraid to admit to their doctors that they smoke. We might succeed in denying surgery to some smokers, but we would lose the trust in the doctor-patient relationship for a large percentage of the population, as well as the opportunity for physicians to appropriately diagnose and treat patients who have a major risk factor for a number of severe diseases.

Just as physicians should advise patients to improve their nutrition, lose weight, and exercise before surgery to promote the best possible outcome, they should also advise their patients to quit smoking. But it doesn't make sense for the consequences of the patient failing to lose weight, eat properly, or exercise to be having surgery offered anyway, but for the consequences of the patient failing to quit smoking to be being denied surgery.

Perhaps the most disturbing aspect of Dr. Peters' argument is that it would require physicians to act in a way that is often not in the best interests of their patients, violating a central and essential tenet of medical practice. If a smoker does not succeed in quitting smoking, then it is almost certainly in his or her best interest to have surgery anyway, especially for something like an orthopedic procedure where his or her quality of life will be greatly affected by the failure to perform the procedure and where the chances are still much greater than not that there will be no complications from the surgery due to continued smoking.

In these cases, the physician would be enforcing on her patient a decision that is not in the patient's best interest, but is mandated because of a societal judgment that smoking is the one behavioral choice that affects surgical risk that cannot be tolerated.

As Dr. William Cameron said so eloquently in his rapid response to the article: "The role of the physician whose proper client is his patient is to act in that individual person's best interests. Otherwise, the physician should confess the competing interest (like some notion of the public purse) to his patient, and if conflicted, refer the patient to an unbiased provider. If a person or his disease is distasteful to a physician, he should confess and refer, rather than construct arguments that rationalize, or worse impose the prejudice by policy in disfavouring one person for another. All persons should be considered equal in dignity and rights, and triage for access to limited resources should be according to need, not by social or any other lottery. If it is the mission of a well-meaning physician to 'fight smoking' then he should address smoking, not the smokers, and surely not in the face of illness and a need for care."

But I can't think of a more fitting closing comment than to share the rapid response offered by Dr. Patrick Silvestre, who wrote: "I really agree with this analysis of the surgical care in smoker's population. I propose also to study carefully the case of obese ones, who are guilty of their bad alimentation, of car or bike users, and their traffic injuries, or the pedestrian who would have to remain at home. Perhaps can we have productive thinking of cost effectiveness of care for the poor and unemployed or more simply, the other, the stranger? What a wonderful medicine, this medicine of the future! I am sorry, it's not mine."

How true. If, in our desire to cut medical costs, we abandon the most basic aspects of medicine - our willingness to provide treatment to people regardless of the circumstances that led to the need for treatment - we will end up causing much more harm than good.

Bangor City Council Bans Smoking in Cars with Children

The Bangor City Council Monday night approved a measure that bans smoking in cars when anyone under age 18 is present. The ordinance was amended to make the violation a primary, rather than secondary offense, meaning that the police are charged with the responsibility of pulling over any car with a minor in which smoking is occurring.

Bangor becomes the first municipality to enact such a law. Two states - Louisiana and Arkansas - have passed car smoking bans and similar bills are under consideration in California, Connecticut, and Maine.

According to an Associated Press article, one councilmember who supported the ordinance compared smoking in a car with children to deliberately trying to kill your child: "People who smoke with children present in the confined space of a car or truck might as well be deliberately trying to kill those children, said City Councilor Patricia Blanchette, who is a smoker. 'Let's step up to the plate and lead; our children are worth the fight,' she said."

A number of speakers at the hearing did testify in opposition to the measure. According to the Bangor Daily News: "Aaron Prill of Bangor said the ordinance was a "feel-good option" that was not intended to protect children but to "moralize" against smokers. ... Children are exposed to more smoke in their homes than in cars, said Eugene Savoy of Davis Road in Bangor. ... Councilor Susan Hawes said police should devote their energies to more important issues, and that there's already too much government intervention in residents' lives."

The Rest of the Story

What this story demonstrates, ironically, is precisely the opposite of what Councilmember Blanchette suggests. Rather than stepping up to the plate and leading to protect children from a behavior that is apparently tantamount to intentionally killing them, the Bangor City Council has cowardly refused to address the issue and instead, decided to allow kids to apparently continue to die from secondhand smoke.

If Councilmember Blanchette is correct and exposing a child to secondhand smoke is tantamount to deliberately trying to kill them, then how can she possibly justify allowing parents to attempt to kill their kids by exposing them, day in and day out, for hours and hours, to secondhand smoke in the home?

If Councilmember Blanchette truly feels that it is her responsibility to step up to the plate and lead and that "our children are worth the fight," then how can she possibly justify not stepping up to the plate and protecting kids from secondhand smoke in the home, which is by far the primary source of secondhand smoke exposure for kids?

Apparently, the Bangor City Council is not willing to step up to the plate and apparently, our children are not worth the fight.

Because that is essentially the message that the City Council has sent. Our children are only worth the fight when it is politically easy to protect them. To protect them from short and infrequent exposures to secondhand smoke, the Council will step up to the plate. However, to deal with the real cause of tobacco smoke-related childhood illness - home exposure - the Council decided to do nothing.

If the Bangor City Council was truly sincere about its desire to protect children, it would have protected children. If secondhand smoke is truly the threat that the Council claims it is, then it would have acted to protect children from that threat. And to protect children from that threat, you have to protect them from secondhand smoke exposure in the main place where they are exposed - the home.

Apparently, the Bangor City Council does not have the fortitude to put its actions where its mouth is. They can talk the talk, but they're not willing to walk the walk.

Sure - it sounds great that the Council is stepping up to the plate and doing something to protect the children, but the truth is that the overwhelming bulk of secondhand smoke exposure among Bangor's children occurs inside the home.

I am very anxious to hear the Council's justification for failing to protect children from a hazard in the home which they themselves have admitted is essentially equivalent to intentional efforts to kill those children.

Obviously (at least to those familiar with my commentary), I am not suggesting that banning smoking in the home is an appropriate policy. What I am pointing out is that the Bangor City Council's action is a politically correct, feel-good, and cowardly measure that allows them to talk about how deadly secondhand smoke in cars is and makes them feel like they have done something to protect children from this life-threatening hazard, when in fact, they have actually done little to protect the public's health and ironically, have decided to allow parents to, in the Council's own words, intentionally attempt to kill their children in their own homes.

There is only one way out of this mess. And that is to argue that it is not appropriate for government to interfere with parental autonomy - that we as a society tend to give parents the autonomy to make their own decisions about health risks to which their children are exposed - and therefore, that the Council cannot ban smoking in the home. However, if that is the case, then the same reasoning applies to banning smoking in cars for the purpose of protecting kids from secondhand smoke exposure.

In other words, the Bangor City Council has put itself into a huge quandary. It has made a decision that the interest in protecting kids from the health risks of secondhand smoke justifies government intrusion into the private space of its citizens - their private cars - and that it also justifies removing parental autonomy to make decisions regarding exposures that affect their childrens' health risks. Thus, the Council can no longer argue that there is anything stopping them from banning smoking by parents in the home when children are present. Any failure to do so is now merely political cowardice. Or - perhaps - a lack of sincere concern over the health of the city's children. The concern seems to be restricted to kids exposed in a car, but kids exposed in the home are not deemed worthy of health protection.

This is precisely why this ordinance is so dangerous. Once we as a society decide that we are willing to invade the privacy of personal space (homes and cars) and interfere with parental autonomy in decision-making merely in order to address behaviors that increase the risk of illness, we have removed the last barrier from the complete intrusion of the government into all aspects of our personal lives. There is hardly anything that we do, or a decision that we make, that does not in some way affect our health risks. Every aspect of our behavior, and every decision we make, could (and should) be subject to government regulation once we break down this barrier of invading privacy and removing autonomy regarding behaviors that merely affect health risks.

On this smoking policy issue, I agree with the opponents to the ordinance. This is largely a feel-good measure. It does little to protect the health of Bangor's children. The only smoking ban that would actually reduce the incidence of secondhand smoke-related illness among the children of Bangor is a ban on smoking in the home.

I do think that this is largely an effort to moralize against smokers. I can think of no other parental behavior that puts children at a small increased risk for illness that the Bangor City Council has banned. Why single out smoking in cars? It does make you think that this is largely an effort to simply send a message to smokers. But why not send a message to parents who feed their kids fat-laden french fries every day? Or parents who expose their kids to hours upon hours of secondhand smoke in the home, for that matter?

I also agree that the Bangor police department has more important things to do than pull cars over because someone is smoking.

The upshot of Bangor's new policy is that smokers with kids are going to become fearful of being seen smoking in public. Instead of risking public shame and humiliation, they are going to confine their smoking to the privacy of their own homes - and that truly is going to represent a health risk for children. In fact, this measure could well make the problem of childhood exposure to secondhand smoke worse rather than better.

University of Iowa Considering Complete Ban on Smoking on Campus

The University of Iowa is considering implementing a complete smoking ban on the entire campus, including all outdoor areas (article 1; article 2).

According to an article on the KRCG website: "The University of Iowa is looking to become one of the first major universities to completely ban smoking. Removing cigarette smoke from the air by 2009 is a lofty goal. A university committee wants to start the discussion now, so Iowa can meet the deadline. The report is already on interim-president Gary Fethke's desk. A plan to gradually snuff out cigarettes until the entire campus is breathing easy. Co-chair of the smoking review policy committee Susan Johnson said, 'The biggest motivation for making changes on campus is the clear risk of danger from second hand smoke.'"

Later in the article, however, Johnson admitted that there is not evidence showing any significant risks of secondhand smoke exposure encountered while walking past a person smoking outdoors: "The committee is in favor of banning smoking everywhere, but realizes it could be an unpopular decision. Here is at least one issue to consider. Johnson says there are few, if any, studies showing a danger of inhaling as you walk past a person smoking. Most second-hand smoke studies involve heavy smoke like in a bar."

There is already an existing ban on smoking in campus buildings and outside these buildings within 25 feet of any entrance.

The Rest of the Story

The first point to make clear is that the true purpose of a complete ban on smoking on the entire campus - including all outdoor areas - cannot possibly be to protect people from the dangers of secondhand smoke. You don't need to ban smoking everywhere outdoors in order to accomplish that. As the head of the smoking policy review committee herself admitted, there are no studies showing the danger of inhaling secondhand smoke as you walk past a person smoking.

So there is something more than simply protection of nonsmokers involved with this proposal. Clearly, the proposal aims to address the health issue of smoking in general and to promote a healthy campus.

There are just a couple of problems with this, however.

First, if the University of Iowa were truly interested in promoting a healthy campus, the first thing it would have to do is create an alcohol-free campus. Without much doubt, alcohol use on campus causes a much greater and more severe threat to the health of students and college community members than drifting tobacco smoke outdoors.

According to the University's student health services, 69% of University of Iowa students report having engaged in dangerous drinking. About two-thirds of students reported having experienced hangovers, 38% reported missing class or work, 25% reported injuring themselves as a result of alcohol misuse, 22% drove after having had more than one drink, 29% reported having had unintended or regretted sex, 12% had damaged or stolen property, and a whopping 46% reported having had a blackout.

In addition, "the Iowa City ambulance service responded 214 times to alcohol-related issues in the downtown area during a six-month period and around 90 letters are sent home each year to parents of students who have experienced alcohol-related emergencies."

Sadly, the University of Iowa has suffered at least two alcohol-related deaths: one student died after drinking too much at a fraternity event and another student died after falling from a second-story balcony.

If the real concern were the overall health of the campus, it would be alcohol that would have to be banned, not smoking in every remote outdoor area of the campus, every sidewalk, street, walkway, and parking lot.

Second, if you believe that the University needs to ban smoking on campus in order to establish a healthy community environment, then certainly the University should also address the unhealthy food on its dining hall menus.

Scrambled eggs, biscuits and gravy, grilled ham, french toast, and the dreaded tri taters (1 gram of trans fat per ounce!) - and that's just breakfast. And how about Thursday night's dessert of peanut butter cookies, jell-o cake, and chocolate cream pie? (If I ever give a talk at the University of Iowa, I'll be sure to arrange it for a Thursday).

The University's residence halls have some excellent fat-laden items on their menus. Take, for example, the beef pot pie: 450 calories and 30 grams of fat! Or the sirloin steak: 710 calories and 60 grams of fat. Topping off your meal with a cream puff adds another 250 calories and 17 grams of fat. Thursday night's chocolate cream pie adds 350 calories and 13 grams of fat. My personal favorite - the tater tot casserole - has 345 calories and 15 grams of fat (but is worth every one of those calories). And the tater tots, which curiously are listed under vegetables, weigh in at 255 calories and 14 grams of fat.

And if you're worried about how many tri-taters you're given at a gram of trans-fat per shot, don't worry. The University has an all-you-can-eat policy, boasting that "you won't go away from Residential Dining hungry. We offer unlimited helpings on all items at every meal."

If that's the case, then please get me to Iowa City on a Sunday evening, when they feature the Kansas City barbecue pork ribs, cheesy corn bake, and hickory black beans. Or if I can't schedule my trip for a weekend, then I'll take Wednesday evening's North Carolina pulled pork, creamy coleslaw, and hushpuppies.

Between the alcohol abuse, the alcohol-related deaths, and the high-calorie, fatty food on the dining hall menus, I think that the campus has a whole lot more important health issues to worry about then if a person might possibly breathe in a few whiffs of tobacco smoke while walking past a smoker on a sidewalk somewhere.

Once again (just as in yesterday's post), it appears that something other than simply a sincere concern for the health of the student body is at work here. Why would smoking be singled out as the sole unhealthy behavior that will not be tolerated on campus? Once you set aside the concerns about secondhand smoke, which clearly do not necessitate a complete ban on smoking everywhere on campus, what separates smoking from drinking alcohol or overindulging in cream puffs and hushpuppies?

To me, the singling out of smoking again suggests that what is really going on here is moralizing, punishing smokers, showing intolerance and trying to drive smokers away from the campus.

This is not the direction that I think the anti-smoking movement should be going. Don't we know when to stop? Isn't it enough to protect nonsmokers from secondhand smoke exposure in workplaces and places where they cannot avoid exposure?

The irony is: in Iowa, they seemed to have jumped over the first step. Local towns and cities cannot even pass bar and restaurant smoking laws and the state law does not require smoke-free workplaces. But soon, you can rest assured that you won't be exposed to drifting tobacco smoke in a parking lot in Des Moines, or on a sidewalk on the University of Iowa campus.

Bangor City Council to Consider Car Smoking Ban Tonight

This evening, the Bangor (Maine) City Council will consider a proposal to ban smoking in cars with children present. No person would be allowed to smoke in a car if anyone under 18 were present. The penalty would be a $50 fine, but the offense would be a secondary one - this means that the police could not pull over a motorist for smoking in a car, but could only issue a ticket if the person were pulled over for some other reason.

According to an article in the Bangor Daily News, the measure is being supported by a number of public health groups.

The push to ban smoking in cars with children present is gaining momentum across the country. Arkansas and Louisiana have enacted such legislation, California is considering legislation now, and similar legislation will be considered in Connecticut during the upcoming legislative session.

The Rest of the Story

In the reader comments to the Bangor Daily News articles, a number of Maine residents make some compelling arguments which I think need to be considered.

For example, EJ states: "I understand the need to protect the children. But what about the children that are overweight...I cringe everytime I see a parent buying fast food french fries for their overweight/obese child. Facts: Doctors are finding that more and more severely overweight children have medical problems such as a fatty liver, a precursor to liver disease, high blood pressure, and an increasing likelihood of Type 2 diabetes. In addition, obese children are becoming prime candidates for heart attacks and strokes even while in their teens. Researchers say it's important to realize that obesity is a health problem -- not a judgment about how people's bodies should look. Everyone has their own idea about how they like to look, but nobody wants to have a heart attack. I have to ask, will there be fines against the parents that contribute unhealthy diets for their children as well?"

This is a very strong argument. If we are willing to interfere with parental autonomy to make decisions regarding health risks to which their children are exposed, then we should be willing to regulate exposure of kids to fast food and a host of other health hazards and not only to secondhand smoke. So the same reasoning that would justify the imposition of a ban on smoking in cars would also justify regulations on many other health-related risks to which parents expose their children.

Anti-smoking advocates who are concerned about regulating children's exposure to secondhand smoke would want to focus first on exposure in the home, since it far exceeds exposure in cars, which is short in duration for most children. Parents who smoke in a car are also likely to smoke in the home, and the duration of this exposure is almost certainly going to be far higher than car exposure for the overwhelming majority of children, if not for all of them. So it makes no sense to ban smoking in cars with children present and yet allow smoking in homes with children present. And once you are willing to interfere with parental autonomy and regulate behavior in a private car, there is no reason not to also regulate behavior in a private home.

But medical, public health, and anti-smoking advocates in Bangor are not calling for bans on smoking in the home, nor for regulation of many serious health risks to which parents in Bangor expose their children - these advocates are only calling for banning smoking in cars. Moreover, they are apparently not too serious about enforcing this proposed law, because they propose to only make it a secondary offense, which essentially means that it is just there to rub someone's face in the dirt once he or she is already pulled over for speeding or some similar moving vehicle violation. This leads me to question the sincerity of these advocates in terms of the strength of their commitment to protecting the health of the children from risks that they apparently consider to be unacceptable.

And more importantly, it leads me to question the real intent behind the proposal. Quite clearly, the intent does not seem to be to protect children from secondhand smoke exposure. If it were, the advocates would be calling for smoking in cars to be a primary offense, and for smoking in homes with children to also be banned. Instead, they are merely proposing a "feel-good" law that will make them feel better, but will do little to actually protect childrens' health.

The proposal, then, essentially amounts to little more than moralizing. It is turning smoking into a morally unacceptable behavior, not merely a behavior that poses health risks. Smoking around children is being singled out as a behavior that is morally unacceptable; all other parental behavior that exposes children to health risks is not morally unacceptable - it is merely a health risk.

Why this distinction? Why this inconsistency?

The answer, I believe, is that anti-smoking groups have increasingly been turning the smoke-free movement from a public health movement to one that is essentially a moral crusade.

And instead of aiming to truly help smokers, which was the primary reason behind my decision to dedicate my career to tobacco control, we as a movement are increasingly trying to punish smokers and make their lives more difficult because of intolerance and social ostracization.

If we truly wanted to help smokers, then we would take Rae-Shawna's excellent suggestion and provide low-cost or free smoking cessation assistance to smokers who want to quit: "I don't get it! Millions of dollars are spent on helping to clean up drug addicts & alcoholics, but no one helps the smokers! The helpline is a joke! Smoking is an addiction! I can't afford to pay $50-$100 for help to stop, but I can usually come up with $5 for a pack of cigarettes! Now you want to fine people for smoking! Are you kidding me? I've got drug dealers and pedophiles moving into my quiet neighborhood and no one does anything to them, but because I smoke I risk being fined!? Please take care of the real criminals first! Most of your smokers are from low to middle class incomes and can't afford the high cost of quitting. If you really want to help smokers stop smoking...come up with a way to help them that they can afford!"

Attempting to regulate smoking in cars is not, in my opinion, a good way for the tobacco control movement to begin the new year in 2007.