Friday, March 17, 2006

The 20-30 Minutes Fiasco: Why Anti-Smoking Groups Providing Inaccurate Health Information is Unethical

While I have been arguing for some time that making fallacious scientific claims ("health" claims) is wrong, there has been, so far, no response from anti-smoking groups or advocates, other than ad hominem attacks on me, a defense of the organizations in question, and a questioning of why it is such a big deal anyway.

In this post, I will address the issue of why this is a big deal.

I have already discussed why I think this is a big deal in terms of its implications for the effectiveness of the tobacco control movement. I believe it will undermine the credibility and reputation of the movement and therefore make it increasingly more difficult to be taken seriously when we do make legitimate scientific claims.

Here, however, I argue that regardless of any effect on the movement's credibility, it is wrong simply because it is unethical.

For those who may not be regular readers of this blog:

ASH's fallacious claims are that 30 minutes of exposure to drifting tobacco smoke increases a nonsmoker's risk of a fatal heart attack and actually increases that risk to the level of a smoker.

SmokeFreeOhio's fallacious claims are that 20 minutes of exposure to secondhand smoke increases the risk of a heart attack in nonsmokers and reduces the ability of the heart to pump, and that 120 minutes of exposure increases the chances of suffering a fatal or catastrophic arrhythmia.

The Rest of the Story

It is important to recognize that the principle of providing accurate health information is a basic ethical principle of public health.

An editorial in the American Journal of Public Health, entitled "The Challenges and Opportunities of Ethics" (see: Dickens BM. Am J Public Health 2005; 95:1094), emphasizes "the responsibility of public health practitioners and scientists to conduct their practices ethically."

Specifically, the editorial suggests that the kind of ethical concerns that apply to individual research with human subjects should also apply at the collective level, and not only to research, but to the very practice of public health.

It is easy to see why it would be unethical to mislead an individual subject in a public health intervention about the reasons for such an intervention. But perhaps it is not as easy to see why it might also be considered unethical for a public health organization to mislead a community of individuals (e.g., the public) about the underlying facts regarding the scientific justification for a public health policy proposal.

But the principle of informed consent, if viewed to apply to communities as well as individuals, dictates that the same level of care and scrutiny that is given to communications to individual human subjects also be given to public communications that are attempting to influence the development and adoption of public policies, especially if those communications are designed to stir the public to political action.

The American Public Health Association's code of ethical practice specifies the "community-level" equivalent of the individual-level ethical principle of informed consent:

"Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community'’s consent for their implementation. ... there is a moral obligation in some instances to share what is known. For example, active and informed participation in policy-making processes requires access to relevant information. ...Such processes depend upon an informed community. The information obtained by public health institutions is to be considered public property and made available to the public."

Thus, just as public health organizations must provide individuals with full and accurate information before enrolling these individuals in research studies, public health organizations must also provide the public with full and accurate information that is necessary to make decisions on policies that affect them.

A second core ethical principle of public health practice is truthfulness itself. This was spelled out nicely in a Tobacco Control article (see Fox BJ. Framing tobacco control efforts within an ethical context. Tobacco Control 2005;14[Suppl II[:ii38-ii44).

While it may seem obvious, I think it is worth being explicit about the fact that truthfulness is an important aspect of ethical behavior, not only by individual practitioners but by public health organizations. As Brion Fox points out in his outstanding review of ethical principles in tobacco control practice, if organizations fail to be truthful, they will actually be doing a disservice to the public: "Hence the tobacco control community must hold this principle sacrosanct and strive for disclosing the whole truth, otherwise it may lose its credibility."

These two ethical principles (the community-level equivalent of informed consent and the principle of truthfulness itself) form the essential basic requirement for all public health communications, especially those designed to influence public policies.

One important aspect of these principles that needs to be emphasized is that they condemn not just the dissemination of scientifically false information, but also the publicizing of incomplete information that may distort or hide the whole truth.

Thus, it is not only unethical to provide false health information to the public, but it is also unethical to mislead the public by omitting certain essential information that may result in a distorted or incomplete view of the scientific facts.

An article in last year's Tobacco Control provides a very nice articulation of the basis of the public's right to accurate health information from public health organizations (see: Kozlowski LT, Edwards BQ. "Not safe" is not enough: smokers have a right to know more than there is no safe tobacco product. Tobacco Control 2005; 14[Suppl II]:ii3=ii7).

Kozlowski and Edwards describe the public's right to accurate health information as deriving from the principles of autonomy and self-determination, and note that this right is supported by the Universal Declaration of Human Rights. The principles of autonomy and self-determination also are the basis of the doctrine of informed consent. As a result, "a right to be 'properly informed' suggests that the very act of informing must be undertaken with care and consideration."

According to Kozlowski and Edwards: "Individuals have a right to health relevant information; without it they cannot make meaningful health choices. Promoting and ensuring access to available knowledge is an obligation that follows from this right. ... Tobacco control information campaigns have sometimes fallen short of meeting the obligation of health relevant information. Failure can take many forms. Not informing that a product or activity involves health risks is one obvious example. Providing wrong or incomprehensible information would be another. Saying too little can also be deceptive and a violation of rights."

The authors of this paper specifically address the issue of web-based health communications: "Much of the health communication we discuss employs the internet, and ethical guidelines have been established specifically for the internet (as is discussed in the US Healthy People guidelines in health communication and health literacy). These guidelines are unambiguous on honesty: 'Be truthful and not deceptive.' They emphasize the importance of providing accurate and well supported information. There is no allowance for the use of deception in web based health communications."

Here, another important ethical concern deserves emphasis. It is not enough, according to these ethical guidelines, to simply provide information that is devoid of factual misrepresentations. Public communications must also be well supported by scientific evidence and should not be misleading, even if they are factually accurate.


It should be quite clear that the public communications presently being disseminated by Action on Smoking and Health and SmokeFreeOhio are disrespectful of the individual right to accurate health information. In this case, the communications represent what are clearly scientific misrepresentations of the truth. In other words, the communications are simply inaccurate. But even if the statements were merely deceptive, they would also represent unethical conduct on the part of the organizations delivering these messages to the public.

Even if someone were to argue, therefore, that by some technicality, the communications are not blatantly false (I think they are, but let's stipulate that someone could make an argument that they are not inaccurate by virtue of some technicality), they are still massively deceptive and therefore unethical.

Anti-smoking groups may provide a utilitarian-based argument that these inaccurate and/or misleading communications are doing more good than harm in the long run because they are helping to promote smoke-free policies which will protect the public's health and save lives. The problem is that even if this were true, the violation of these basic ethical principles is a core value of public health practice that cannot and should not be sacrificed. The ends do not justify the means, especially when those means are violating principles of autonomy and self-determination that form the essential bases for free societies.

Finally, while simply making mistakes in putting out a communication is excusable (we all do it), once the inaccuracy is called to the attention of the group and the group fails to correct it, then we are talking about a clear failure to exercise "care and consideration" in "the act of informing."

This appears to be the case with the 20 minute and 30 minute fiascos.

The rest of the story is that the dissemination of fallacious information by anti-smoking groups to the public in support of smoking bans is not only unfortunate because it is going to harm the tobacco control movement by undermining its credibility, reputation, and effectiveness, but because it is unethical and disrespectful of the basic principles of truthfulness and scientific accuracy in health communications, which are in turn founded on the principles of autonomy and self-determination, values which cannot and should not be trodden upon by public health organizations in free societies simply to promote a favored policy.

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