Monday, July 28, 2008

IN MY VIEW: The Increasingly Aggressive War on Smokers -- Why We are Headed in the Wrong Direction

The proclamation by the New York State chapter of the American Cancer Society that smokers are poor role models for their children and its seeming acceptance by anti-smoking groups got me thinking about the drawbacks of what I see as an increasing war on smokers, rather than a battle against smoking, cigarettes, or the tobacco industry.

First, it strikes me as odd that we would be declaring war against smokers, since I am in this business in the first place specifically because I saw the suffering of my smoking patients. My inclination was not to attack them, but to try to help them. The goal, I thought, was to try to reduce future suffering due to tobacco-related diseases, not to try to make the lives of smokers miserable and to marginalize them out into the periphery of society.

But there is no question in my mind that the tobacco control movement has now crossed the line from being anti-smoking to being anti-smoker. In the past months on this blog, I have brought forth numerous stories about tobacco control actions that I believe have no health justification, but which do make the lives of smokers more difficult, make it harder for them to obtain jobs and support their families, or which strip them of their rights. All of these lead to the marginalization of smokers, which unfortunately has adverse health consequences in its own right.

The anti-smoking group's comments about the lack of value of smokers as role models for their children demonstrates the important, although perhaps subtle to anti-smoking advocates, distinction between a perspective that is appropriate and one that is not. The American Cancer Society's comment demonstrates the line that separates public health from bigotry.

Smoking, like eating Vienna Fingers, drinking alcohol, watching violent movies, and eating lots of fatty foods, is certainly not setting a good example for children. That is - the behavior does not set a good example. But this is different from saying that the person - the smoker - is a poor role model. Just like the father who eats Vienna Fingers and lots of other fatty foods may very well be an excellent role model for his kids, so may be the smoker. The point is, it is not health-related behaviors that determine whether one is a good role model for children. We do not ascribe moral value or attribute character or integrity to most health behaviors.

Would the American Cancer Society also say that a fat person is a poor role model for children? Suppose that fat person doesn't get enough exercise and consumes too many calories (which, by definition, is almost always the case). Would the Cancer Society also say that this individual is a poor role model for children?

Are fat people poorer parents than normal-weight ones?

For public health practitioners, the answer is clearly no. For physicians, the answer is also no. For bigots, the answer is yes.

The same is true of smoking. While the behavior of smoking does not set a good example, stating that smokers are poor role models for their children is an example of bigotry.

If the American Diabetes Association came out and stated in a newspaper article that fat people were poor role models for children, I would bet that there would be widespread condemnations of the statement for its bigotry, intolerance, and insensitivity. The same should be the case for the American Cancer Society's statement that people who smoke are poor role models for children.

In addition to the kinds of comments offered by the American Cancer Society, there are numerous aspects of the modern-day anti-smoking agenda which are intended to marginalize smokers:

1. The promotion of policies that restrict employment to nonsmokers -- As I have documented on this blog, a number of tobacco control groups are supporting policies that restrict employment to nonsmokers. The World Health Organization, Cleveland Clinic, Weyco, Scotts Miracle-Gro, and Truman Medical Centers are just a few examples of companies that refuse to hire smokers.

2. The advocacy for policies that treat smokers as child abusers -- A number of anti-smoking advocates have called for smokers who expose their children to secondhand smoke to be treated as child abusers.

3. Support for the refusal of physicians to treat or operate on patients who smoke -- This trend continues to grow. Just this past Thursday, the BBC reported that experts are considering denying IVF treatment to smokers.

4. Support for the refusal to allow smokers to adopt children or serve as foster parents -- Some anti-smoking groups are pushing for smokers to be ineligible to adopt children or to serve as foster parents.

5. Support for, and promotion of efforts to ban all smoking on college campuses -- This is a growing trend, and has no relevance to protecting nonsmokers from secondhand smoke. The aim is to prevent anyone from merely seeing anyone smoking on campus.

6. Support for policies that ban smoking entirely outdoors, including parking lots, streets, and sidewalks -- An example of this trend is the recently enacted policy in Hayward, California which bans smoking on streets and sidewalks. These policies are not necessary to protect people from secondhand smoke, but do give police a legal mechanism to get rid of "undesirable" smokers.

All of these policies are intended to, and have the effect of, marginalizing smokers. What public health advocates need to realize is that the marginalization of a group of people has its own set of adverse effects on health. Not the least important of these is that it makes it much less likely that these people are going to want to quit smoking. When people feel that their lives are being controlled, they are less likely to feel a sense that they can control those aspects of their lives and less likely to have such a desire. Marginalization creates a self-fulfilling prophecy, if you will, that supports the maintenance of the behavior in question.

In addition, marginalization of a group of people has been well-documented to have adverse health consequences. People who are stigmatized may internalize society's hateful feelings, resulting in emotional stress and turmoil and a number of adverse health consequences.

I think that it is time to return the tobacco control movement to being an anti-smoking movement, rather than an anti-smoker movement. We need to abandon workplace smoker policies in a return to workplace smoking policies. We need to ensure that in all of our interventions, we are respecting the autonomy, freedoms, and rights of smokers and not casting moral judgment upon them.

In closing, one of the most important tenets of medicine and public health is that we do not cast moral judgment about our patients (in the case of physicians) or the public (in the case of public health practitioners). We view smoking as an unhealthy behavior, but we do not cast moral judgment on the smoker. We do not refuse to treat smokers or to allow smokers to enjoy privileges and advantages that other members of society enjoy simply on the basis of their having chosen to smoke, unless there are direct medical contraindications.

The tobacco control movement is increasingly violating this tenet of public health practice, and in my opinion, crossing the line from public health to bigotry.

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