Public Health Groups Attack New Cigarette Ads, Fail to Reveal Public Health Corporate Partner of One Company that is Carrying the Ads

A number of public health groups, including the Campaign for Tobacco-Free Kids and the National Latino Council on Alcohol and Tobacco, today denounced a new cigarette marketing campaign they allege is aimed at recruiting Latino youths to smoke.

According to the press release: "In recent months, the R.J. Reynolds Tobacco Company has launched an elaborate, expensive new marketing campaign for Kool cigarettes that has included ads in publications popular with Latino youth, including Latina and Cosmopolitan en Espanol. The ad campaign, which includes an eight-page insert in some magazines, features multicultural images and slogans intended to appeal to the aspirations of ethnic minorities, including "It's about old world class and new world style" and "It's about pursuing your ambitions and staying connected to your roots. ... 'It is outrageous that the tobacco companies are exploiting the aspirations, culture and images of the Latino community to market deadly and addictive tobacco products to our children.'"

"'The tobacco companies are spending more than ever before to go after our children, including Latino children. That is why it is so important that we fight back with strong programs to protect our children,' said Guillermo Brito, executive director of the National Latino Council on Alcohol and Tobacco Prevention."

The Rest of the Story

One tobacco control group that is not fighting back "with strong programs to protect our children" is the American Legacy Foundation, which is actually helping to reinforce the ad campaign targeted at the Latino community, I believe, by partnering with one of the very companies that is responsible for delivering these ads to children: namely, the Hearst Corporation - publisher of Cosmopolitan.

For an outline of the American Legacy Foundation's contributions to the health of women in the United States through their support (through corporate partnerships) of magazine publishers that are bombarding women and girls with cigarette advertisements, see my previous post.

More Misleading Claims Found in Tobacco-Free Kids' Campaign of Deception to Promote FDA Legislation

According to the Campaign for Tobacco-Free Kids' "fact" sheet on the proposed FDA tobacco legislation: "The public health community supports strong, identical, bipartisan bills that have been introduced in the Senate and the House of Representatives."

The Rest of the Story

I find the Campaign for Tobacco-Free Kids' claim that the public health community supports the FDA tobacco bills to be misleading and disingenuous.

The claim is not that "The Campaign for Tobacco-Free Kids" supports this legislation, or that "A coalition of public health groups" supports this legislation. Instead, it's that "The public health community" supports this legislation.

To me, that implies that there is not a substantial amount of dissent in the public health community about support for this legislation. And I simply do not think that implication is accurate.

A large number of very prominent public health advocates with years of experience in tobacco control have expressed their opposition to this legislation. There has been a published commentary in the journal Tobacco Control that opposes this legislation. And that commentary was published in the "Debate" section, apparently indicating that there is some debate in the field about the merit of this legislation. There is a web site devoted to opposition to this legislation. And a large number of public health advocates are clearly opposed to the measure. And the Campaign for Tobacco-Free Kids knows it.

While I disagree with the Campaign's characterization of this legislation as being "strong" (I do agree that the bills are "identical" and that they are "bipartisan"), I don't take issue with that characterization because the Campaign is entitled to its opinion and is entitled to state its opinion in its own "fact" sheet.

However, the Campaign is not entitled to misrepresent the position of the public health community in order to enhance its Campaign of Deception to promote this Philip Morris-supported legislation.

If the Campaign wants to express its own support for the bill - fine. If it wants to express the support of a large number of organizations - fine. But it is not entitled to express the support of the entire public health community when there is a substantial segment of the public health community that vigorously opposes this legislation.

Tobacco-Free Kids is entitled to lobby for what they apparently think is the best thing since sliced bread (and Philip Morris apparently agrees). But this campaign of deception has got to come to an end.

Georgia Smokefree Air Act Rules Go Into Effect Today: Poor Excuse for a Public Health Law

Rules to implement Georgia's Smokefree Air Act of 2005 went into effect today, timed to coincide with the Great American Smoke-Out. While the law itself took effect on July 1, release of the rules to guide the law's implementation were delayed because of the need to figure out how to deal with the ban's exemptions: most importantly, whether restaurants that decide to allow smoking by declaring themselves as adult-only establishments need to disallow minors at all times or only when smoking is allowed (the decision was to force them not to allow minors at any time).

According to Stuart T. Brown, M.D., director of the Georgia Division of Public Health: "This new law is important because it reduces the risk of chronic disease and illness associated with exposure to secondhand smoke, and it provides an opportunity for DHR to educate the public about what the law requires and why it is important. ... By prohibiting smoking and preventing secondhand smoke exposure in public places, we can begin to reduce the numbers of tobacco related deaths in Georgia each year, which number more than 11,000."”

The Rest of the Story

I don't view Georgia's Smokefree Air Act of 2005 as a public health law, nor do I even view it as a "Smokefree Air" act. It might more appropriately be called the "Smoke-Filled Air Act of 2005."

Rather than allow restaurant workers in the state to work under conditions where the average nicotine levels are about 6.5 ug/m3, the new law requires restaurant owners who wish to allow smoking (and aren't inclined to ban kids from their establishments) to force employees to work under conditions where the nicotine levels are more in the range of about 70 ug/m3 (see: Siegel M, Husten C, Merritt R, Giovino G, Eriksen M: The health effects of separately ventilated smoking lounges on smokers: Is this an appropriate public health policy? Tobacco Control 1995; 4:22-29).

I don't see how that policy in any way "is important because it reduces the risk of chronic disease and illness associated with exposure to secondhand smoke" or how it in any way prevents "secondhand smoke exposure in public places."

Actually, the policy will increase secondhand smoke exposure and likely, chronic disease among restaurant workers who are unfortunate enough to have to work in these carcinogen-laden smoking areas.

In essence, the Georgia Smoke-Filled Air Act of 2005 guarantees protection from secondhand smoke to not a single bar or restaurant worker in the state of Georgia. It simply puts their secondhand smoke exposure at the whim of their employer:

• If the employer decides to go smoke-free, then they will be treated to smoke-free working conditions.
• If the employer decides to go adult-only, then they will be treated to smoke-heavy working conditions.
• And if the employer decides not to go adult-only but still wants to allow smoking, then those workers will be treated to smoke-filled working conditions.

Essentially, what this law does is simply to force restaurant employers to decide the business category and smoke-exposure category they wish to be in: smoke-free, smoke-heavy, or smoke-filled.

This is not a public health law - it's an arbitrary and capricious intervention into the way that restaurant owners operate their business establishments, and I think it's devoid of any public health justification.

Not only that, but I think it's a disaster for sincere efforts to protect workers from secondhand smoke in this country. Because what it does is set a destructive precedent - one that is sure to be followed by other states and localities. Even several localities within Georgia have apparently weakened their health protections for restaurant workers in order to not be in conflict with this exemption-filled state law.

The precedent is destructive not only because it fails to guarantee any worker protection from secondhand smoke - the alleged hazard here - but because it frames the issue as one of customer protection, and one of youth customer protection at that.

If the state of Georgia was truly interested in reducing chronic disease by preventing secondhand smoke exposure and it truly believed that secondhand smoke exposure was a substantial threat to its workers, then what possible sense does it make to only regulate this hazard insofar as youth customers are concerned. When you look at it, youth customers are guaranteed protection by this law, but adult customers and workers are not.

How could secondhand smoke be a substantial hazard for youth restaurant patrons, but not for adult patrons or bar or restaurant employees? There's just no scientific basis for making such an arbitrary distinction. Secondhand smoke doesn't make a distinction in exposing kids versus adults, or customers versus workers. Neither should a public health-motivated law.

I think that there is something other than a true concern for the public's health that must be motivating this law. In my opinion, it's an attempt to make it look like the state is doing something to address the problem, but to avoid having to actually make the difficult decisions necessary if you actually want to provide protection to the workers in your state.

I realize that some public health advocates in Georgia would likely argue that this law is not perfect, but that it is a step in the right direction. I disagree. I think it's a step in the wrong direction.

If a law isn't justified on public health grounds, then I think it should simply not have been enacted in the first place. Irrational public policy is not a step in the right direction. It is a step down the path to creating a huge public backlash against even legitimate attempts to protect people's health.

Five Days Later: Social Engineering Argument Being Used to Support Outdoor Smoking Bans

Just five days after I cautioned about the use of social engineering as a justification for outdoor smoking bans, it appears that anti-smoking groups in Canada are using exactly such an argument to promote these bans.

According to an article in yesterday's CBC Health & Science News, the great outdoors has become the next frontier for anti-smoking efforts and with the lack of scientific evidence that most outdoor smoking is a substantial public health problem, anti-smoking groups are falling back on an alternate argument to support these bans - that they are necessary to reduce smoking by making it more difficult for smokers to find places to smoke:

"Smoking has been banned in workplaces, restaurants and theatres, leaving the great outdoors as the next frontier for anti-smoking campaigns. 'People understand the concept of air pollution, that it may be everywhere,' said Roberta Ferrence of the Ontario Tobacco Research Unit and the Centre for Addiction and Mental Health in Toronto. 'Somehow [with] second-hand smoke outdoors they feel it's magically whisked away, and it isn't.'

The governments have acted although there is little published research on levels of outdoor second-hand smoke or its health implications. Ferrence's colleague, Pam Kaufman of the Ontario Tobacco Research Unit, points to other reasons to ban or reduce outdoor smoking. 'Studies have shown that with restrictions, people are more likely to quit and possibly cut down on the amount that they smoke, even if they don't quit.'"

The move to ban smoking outdoors is apparently being viewed by some as not being motivated by a concern for protecting people's health, but as being an attempt at telling people how they should behave: "For Filip Palda, an economist and senior fellow at the Fraser Institute, the move to restrict or ban smoking outdoors is less about protecting people's health than preaching."

The Rest of the Story

I think this article seems to confirm my impression that backed into a corner because of the difficulty of presenting scientific evidence that most outdoor smoking is a substantial public health hazard that is causing substantial disease among nonsmokers, anti-smoking groups are now having to "scramble to try to justify their actions - and they come up with new ways of defending their actions, resorting to weaker and weaker arguments to do so."

As I have attempted to explain, I do not see the social engineering argument as being an appropriate justification for outdoor smoking bans because I simply do not think it is an appropriate function of public health practitioners to regulate lawful, individual behavior in public places simply so that people will not see behaviors that could be harmful to them.

I don't think we want to start down that road. Should public health practitioners support laws that ban eating french fries in public because it might help encourage poor nutrition? Should we support laws that ban drinking alcohol in public places in order to prevent kids from seeing alcohol use?

Or perhaps even more on the point, should we ban smoking indoors (e.g., in restaurants) simply because we know it will decrease smoking among adult smokers and reduce the exposure of youths to people smoking in public?

If that justification for banning outdoor smoking holds, then it also holds for banning all smoking outside of private homes. Under that reasoning, I see no adequate explanation for why anti-smoking advocates should not be demanding that all smoking in public be banned completely.

As I predicted, a backlash appears to have started already. The move to ban smoking outdoors is being publicly cast not as a public health measure, but as "preaching."

The scariest aspect of this story, however, is its potential ending. According to the article: "For their next move, anti-tobacco advocates say they want governments to address what they consider a form of child abuse: parents who smoke in their own cars or homes with children present."

While I find it disturbing that parents would subject their children to substantial levels of cigarette smoke, I don't think the government can properly intervene and ban smoking in private homes.

And while I find it disrespectful of the health of children to expose them to cigarette smoke, I in no way see smoking as a form of child abuse.

The rest of the story seems to confirm that, in the absence of solid scientific evidence to support the need for outdoor smoking bans, anti-smoking groups are indeed using the social engineering argument as a justification for these bans. I think the argument fails, and I hope that most of the bans do as well.

ENDING THE HYPOCRISY - Double Challenge Issued to Campaign for Tobacco-Free Kids and Ignite: Demand Strengthening of FDA Legislation

According to the Campaign for Tobacco-Free Kids' web site, it believes that "special protection" for the tobacco companies should be ended. Let's see whether they really mean it or if they're simply talking out of both sides of their mouth, like they accuse the tobacco industry of doing.

The proposed FDA legislation that the Campaign, along with Philip Morris of Big Tobacco, are currently supporting would provide the following special protections for Big Tobacco:

• ensure that any decision to eliminate the addictive chemical - nicotine - from cigarettes would be a political, rather than a scientific decision by putting it into the hands of Congress;
• ensure that any decision to require changes in the product substantial enough that the courts could interpret it as eliminating an entire class of cigarettes would be a political, rather than a scientific decision by putting it into the hands of Congress;
• prohibit the FDA from increasing the legal age of sale of cigarettes;
• prohibit the FDA from eliminating tobacco sales in pharmacies, as well as any other specific type of retail outlet;
• require the FDA to make cigarettes the only drug that it regulates for which it cannot require a doctor's prescription, thus ensuring widespread access to this deadly drug by kids;
• ensure that all decisions regarding the regulation of tobacco products, unlike those regarding any other consumer product regulated by FDA, would be political rather than scientific ones by specifically granting Congress the authority to overturn any major FDA tobacco regulation deemed necessary to protect the public's health

If the Campaign is really serious about ending special protections for Big Tobacco and providing for the regulation of tobacco products in the same way that other drugs are regulated by FDA, as it claims, then it will certainly demand that these special protections for Big Tobacco be eliminated from the legislation.

Now Ignite, a youth tobacco control advocacy group funded in part by Tobacco-Free Kids, also is promoting the Philip Morris-supported FDA legislation. And according to Ignite's web site, it also believes that special protections for the tobacco companies should be ended. Further, it appears to believe that public policy decisions should be based on the public's health, not on the basis of protecting Big Tobacco:

"The tobacco industry is just not accountable to the public. Citizens cannot force tobacco companies to change ... But our public officials do hold this power. They have the responsibility of protecting public health and regulating businesses, specifically, to ensure they do not harm consumers. ... Why does Big Tobacco get special treatment from our government? It shouldn't. ... It's time for members of Congress to stop giving tobacco companies special protection. We call on our public officials to step up to the plate."

OK - now let's see whether Ignite really believes what they are saying and is willing to step up to the plate. If they truly believe that Big Tobacco should not get "special treatment from our government," then they most certainly would agree that there is no reason why Big Tobacco should enjoy a huge number of special protections (listed above) that manufacturers of drugs currently regulated by FDA do not enjoy, including ensuring that politics, and not science and public health, is the ultimate arbiter of the regulation of this deadly product.

So here's the simple challenge to the Campaign for Tobacco-Free Kids and Ignite: demand that the FDA legislation be amended to eliminate these truck-size loopholes. It's that simple. You demand an end to these special protections for Big Tobacco and you win the challenge. And more importantly, you regain some credibility in having people believe that you mean what you are stating and that you are not speaking out of both sides of your mouth.

Let's see who, if any, will be the first to win this challenge by demanding the removal of these truck-size loopholes in the FDA legislation that provide unprecedented and unconscionable special protections for an industry that "is responsible for more than 3,000 people dying every three days."

Every day the Campaign for Tobacco-Free Kids and/or Ignite fail to act, "another 1,200 Americans die from tobacco use and another 2,000 kids become addicted."

Ignite Corrects Inaccurate Statement; Young People Should Be Commended for their Integrity

Possibly in response to my October 19 post pointing out an inaccurate statement on the Ignite web site, the group has corrected the statement.

On October 19, I wrote: "On the Ignite (a youth/young adult anti-smoking advocacy group) web site, it states: 'Even though tobacco is addictive and causes over 400,000 American deaths every year, tobacco is still the only consumer product not regulated by the FDA.' To be lenient, that is an inaccurate statement. To be more harsh, it's a lie. It's simply dishonest to publicly claim that all other consumer products (other than tobacco) are regulated by the FDA."

Ignite has, however, corrected the web site, which now states - accurately - that: "Even though tobacco is addictive and causes over 400,000 American deaths every year, tobacco is still [the] one of the only consumable products not regulated by the FDA."

I want to applaud Ignite for taking the time and showing the concern to correct this statement. It takes character to admit making a mistake and it demonstrates integrity to care enough to correct the mistake.

The Rest of the Story

In contrast to the actions of Ignite, which seem to indicate that it truly cares about the accuracy of its public statements and accusations, the actions of another anti-smoking group - Americans for Nonsmokers' Rights (ANR) - lead me to question whether ANR does.

Although it has been quite some time since I pointed out how irresponsible it is for ANR to accuse FORCES International of being a tobacco industry front group when ANR itself admits to having no evidence that FORCES is funded by the industry, ANR's unjustified, inaccurate, and undocumented accusation is still present on its web site.

As I stated back on October 5: "When you preface your argument for the inclusion of this group [FORCES] on the list by stating: "For years FORCES has claimed to be a membership organization that did not receive tobacco funding. Internal tobacco industry documents are inconclusive on this point", I think you are exposing that you have a very weak case for the inclusion of FORCES on the list.

I mean - if the evidence on FORCES being funded by Big Tobacco is inconclusive, then isn't it also inconclusive that FORCES is a Big Tobacco front group?"

Nevertheless, in contrast to Ignite, ANR does not seem interested in correcting what I see as its very inaccurate characterization of FORCES. After all, how can you accuse a group of being a Big Tobacco front and yet not be able to document, with even a shred of evidence, that the organization is funded, even in part, by Big Tobacco?

While Ignite's accomplishment may not seem particularly spectacular in and of itself, I have to say that in the midst of an anti-smoking movement that appears to care only about its agenda and not the integrity of the means used to pursue that agenda (including assuming the responsibility of being accurate to the public in one's public statements), Ignite's action to correct its public statement stands out as a rare light in an otherwise dark tunnel.

Pueblo Study on Reduced Heart Attack Rate Following Smoking Ban Cited as Evidence that Secondhand Smoke Causes Heart Disease

A study released yesterday at an American Heart Association scientific conference reports that heart attack rates in Pueblo, Colorado dropped by 27% following the July 2003 implementation of a 100% smoke-free ordinance covering all workplaces, restaurants and bars in the city.

According to the study: "In the year and a half before Pueblo's smoke-free ordinance went into effect, 399 heart attack patients were admitted to the city's two primary hospitals. In the year and a half following enactment of the ordinance, the number of heart attack admissions dropped to 291, representing a 27 percent decrease."

In response to the release of this study, the Campaign for Tobacco-Free Kids informed the public, through a press release, that these data provide evidence that secondhand smoke is a cause of heart attacks:

"The results of these studies should not be a surprise in light of the overwhelming evidence that secondhand smoke poses serious, even life-threatening risks to health."

"The conclusions of these studies are reinforced by the scientific evidence about the impact of secondhand smoke on cardiovascular health. Other studies have found that exposure to secondhand smoke increases the risk of heart disease among non-smokers by as much as 60 percent and that as little as 30 minutes of exposure to secondhand smoke can trigger harmful cardiovascular changes, such as increased blood clotting, that increase the risk of a heart attack."

"The Pueblo study adds to the mountain of evidence that secondhand smoke poses a serious threat to human health."

The Rest of the Story

While the Pueblo study is important because it adds to the evidence that smoke-free laws may result in a decrease in heart attacks, it does not, in my opinion, add to the evidence that secondhand smoke is a cause of heart attacks.

I do not agree that these findings are not surprising "in light of the overwhelming evidence that secondhand smoke poses serious, even life-threatening risks to health," I don't think the conclusion of the study is necessarily "reinforced by the scientific evidence about the impact of secondhand smoke on cardiovascular health," and I don't agree that the study "adds to the mountain of evidence that secondhand smoke poses a serious threat to human health."

Why?

Because the study was unable to (or did not attempt to) determine whether the decrease in heart attacks was attributable to a decrease in secondhand smoke exposure among nonsmokers or to a decrease in cigarette consumption among active smokers (or some combination of the two).

The problem, revealed in the article about the study but not in the Campaign for Tobacco-Free Kids' press release, is that: "The study didn't distinguish between smokers and nonsmokers, but rather represented a combination of both smokers and those impacted by secondhand smoke."

In other words, one cannot conclude from the study that the reduction in heart attacks was due to reduced secondhand smoke exposure among bar and restaurant customers, as opposed to reduced smoking among smokers due to the implementation of the law. The effect of smoke-free laws on reducing cigarette consumption and promoting smoking cessation among smokers has been well-documented.

If I had to take an educated guess, I would guess that the bulk of the reduction in heart attacks was due to reduced levels of active smoking, rather than reduced secondhand smoke exposure. The reason for this guess is that it is difficult for me to imagine that the limited, acute exposure that nonsmoking customers experience while dining or drinking is sufficient to explain 27% of the heart attack burden in Pueblo.

While I believe that secondhand smoke exposure among bar and restaurant workers could be significant enough to cause a measurable increase in their heart attack rates, there are simply not enough of those workers in the city to explain a 27% decline in heart attacks.

The only explanation that I think makes most sense, in the absence of data that would allow one to draw an evidence-based conclusion, is that reductions in active smoking explain the observed effect. It is plausible, based on the extent of smoking in the population and the magnitude of the relationship between smoking and heart attacks, that reductions in smoking could cause a 27% drop in heart attacks in Pueblo, but I don't see the same magnitude reduction in heart attacks being plausible from a reduction in secondhand smoke exposure (unless there were evidence to support such a conclusion).

What I find interesting in the Campaign for Tobacco-Free Kids' response is that the scientific evidence does not seem to be an obstacle in promoting the Campaign's agenda. I actually agree with that agenda (at least as far as promoting smoke-free workplaces goes); however, I would not make a public statement attributing the cause of the observed study findings without what I believe to be adequate evidence to support such a statement.

For a more detailed discussion of my recent observation that the agenda seems to be driving the interpretation of the science in the anti-smoking movement, rather than the science driving the agenda, see my earlier post.

Lest anyone get other ideas, I should make it clear that I do believe that secondhand smoke is a substantial threat to the health of bar and restaurant workers and that policies to protect these workers by eliminating this exposure are warranted. It's just that I try to be careful about making sure that the evidence used to support these policies is sound scientific data from which solid scientific conclusions can be made.

I just don't see how a study which found a reduction in heart attacks that is most likely attributable to reductions in active smoking provides strong evidence for the health effects of secondhand smoke.

While I think this study is important because it documents a rather rapid reduction in heart attacks following implementation of a smoke-free law, the rest of the story suggests that it should not be used to tout the health hazards of secondhand smoke in the absence of data indicating that the reduction in heart attacks was attributable to reduced secondhand smoke exposure, rather than (or in addition to) reduced active smoking.

Lack of Reason in Current Anti-Smoking Agenda Threatens Even Legitimate Public Health Policies: On the Impending Backlash to the Anti-Smoking Movement

I think there is strong reason to believe that in many ways, the greatest obstacle to the tobacco control movement in the near future is going to be the tobacco control movement in the present - specifically, the deviation of the anti-smoking agenda from the bounds of reason, respect, and good sense.

I see the anti-smoking movement as beginning to stray (or possibly, having already strayed) far from the path of reason. When you have a movement that seriously seems to be supporting policies that would deny smokers of the ability to seek gainful employment in many major companies, that supports banning smoking in virtually every outdoor area in order to prevent kids from seeing smokers smoking, and that supports increasingly taxing cigarettes to pay for every government service under the sun (except assisting smokers), I think that movement has started to go too far in its zeal to eliminate smoking, despite how well-placed and appropriate that zeal might be.

DENYING SMOKERS THE ABILITY TO SEEK GAINFUL EMPLOYMENT

The anti-smoking movement appears to be increasingly embracing the idea of supporting employment policies that make not smoking a condition of employment. I'm not talking about smoking at work; I'm talking about smoking off-the-job in the privacy of one's own home. While I think employers have every right to dictate the conduct of their employees on the employers' time, I think when you leave the workplace and start to regulate the lawful behavior of your workers in the privacy of their own homes, you have crossed the line.

The fact that it is perfectly legal (in most states) for employers to fire people because they smoke or to refuse to hire any smoker, that doesn't make it right. And it certainly doesn't make it a reasonable policy that public health practitioners should support, especially those of us in the tobacco control field who should, more than anyone, have an appreciation of the addictive power of nicotine and how difficult it is for smokers to quit.

What we are really doing, I believe, by supporting and promoting these types of policies, is creating a second class of citizens in this country - a class that is going to increasingly find it difficult to obtain and maintain a job.

Is that what tobacco control is supposed to be about? Isn't it difficult enough for smokers, without having to burden them with unemployment and discrimination in the workplace?

BANNING SMOKING IN VIRTUALLY EVERY OUTDOOR AREA

The anti-smoking movement appears to be increasingly embracing the idea of supporting and promoting laws to ban smoking in any outdoor area, regardless of what I believe is the lack of evidence demonstrating that outdoor exposure to secondhand smoke in open, non-enclosed areas where nonsmokers can freely move about is a substantial public health problem. I'm not talking about smoking in an enclosed stadium or in an outdoor workplace where people are restricted in a given area. I'm talking about smoking outdoors in open areas where it is possible for nonsmokers to easily avoid any significant exposure to the smoke. By pursuing these types of policies, I think that we have crossed the line.

The fact that it is perfectly legal to ban smoking outdoors doesn't make it right. And it certainly doesn't make it a reasonable policy that public health practitioners should support.

What we are really doing, I believe, by supporting and promoting these types of policies, is suggesting to policy makers and the public that we view smoking not as a public health problem, but as a nuisance, an annoyance, an evil behavior, a source of litter, and an affront to public morals.

Is that what tobacco control is supposed to be about? Is the goal to cast smokers as immoral people whose addictive behavior we cannot tolerate in public because it is a moral affront? Is the goal to rid ourselves of exposure to litter? Is the goal to prevent any possible nuisance from having to interfere with our enjoyment of life?

INCREASINGLY TAXING CIGARETTES TO PAY FOR EVERY GOVERNMENT SERVICE UNDER THE SUN

The anti-smoking movement appears to have embraced the idea of supporting increased cigarette taxes as a solution to any and all government budget deficits. If you have a budget shortfall in your state, the anti-smoking movement has the solution: balance it on the backs of smokers. I'm not talking about taxes that will raise money to help smokers or to provide much-needed medical care and other services for this segment of the public. I'm talking about eschewing taxes on the wealthiest citizens and corporations in order to take the politically more expedient action of using heavily addicted smokers as the source of needed revenue for government programs. This is, in my view, crossing the line.

The fact that these policies will reduce smoking by encouraging many smokers to quit does not, in my view, make them the right thing to do. And it certainly doesn't make it a reasonable policy that I think public health practitioners should support.

What we are really doing, I believe, by supporting and promoting these types of policies, is balancing state budgets on the backs of the most addicted smokers in the population -- precisely the population that should not have added financial burdens thrown upon them. We know that these individuals are not going to quit (if they did, the policies would not raise revenue, they would decrease it), yet we knowingly agree to force them to subsidize government services for other people that could easily be funded through alternate (yet less politically desirable) means.

Is that what tobacco control is supposed to be about? Are we supposed to be fiscal planners, intervening in government budget debates to promote our own fiscal solutions? Are we supposed to be offering up our clients [the most heavily addicted and poorest smokers], in essence, as the precise individuals to bear the burden for balancing state budgets, and without offering them any direct benefits in return?

The Rest of the Story

The rest of the story, in this case, is more important than the story itself, because what I think this all means is that the anti-smoking movement is setting itself up for a huge backlash. And the shame of it is that this backlash is going to threaten not only the unreasonable aspects of the anti-smoking agenda, but the legitimate and important aspects of tobacco control (many of which I have been working to achieve for the past 21 years).

There's only so long that policy makers and the public are going to go along with the anti-smoking agenda when it starts to deviate from reason, respect, and good sense.

Eventually, people are going to start seeing the anti-smoking movement not as a legitimate public health effort, but as a zealous crusade to try to prohibit smoking and relegate smokers to second class status by ostracizing them and discriminating against them.

Look - I am an ardent tobacco control advocate who has been working in the trenches for 21 years, and I see these efforts as crossing the line. I see these efforts as going beyond the realm of reason and good sense and into the realm of punishing smokers for having had the gall to become addicted to nicotine, largely as youths. I can only imagine what the public, who has not worked in the tobacco control movement for 21 years, is going to think!

Eventually, I think policy makers are simply going to conclude that these anti-smokers are nuts, and they will decide that they have simply had enough. Then, the tobacco control movement will be severely threatened. Legitimate and important policies, such as those to confront the very real and very substantial threats of smoking in the workplace, will fall by the wayside. Attempts to increase cigarette taxes to actually support legitimate tobacco control programs, to prevent kids from smoking, to support smokers in their efforts to quit, and to provide medical care for smokers will be buried.

Simply, it will become nearly impossible to enact legitimate and critical tobacco control policies because we've wasted so much effort on the crazy ones.

The rest of the story suggests that the anti-smoking agenda is being pushed too far. I believe it is beginning to cross the line that separates appropriate public health policy from zealous crusading to get rid of a behavior that one finds abhorrent.

And I'm writing now in the hopes that we can help save the movement by preventing it from going down this road. I don't want responsible tobacco policy when my children grow up to be unavailable because the anti-smoking movement supported the idea of firing anyone who smokes and thus lost its credibility as a legitimate public health effort. And I don't want the policies that I worked to achieve over the past two decades to become unavailable to citizens who don't enjoy their benefits because public policy makers decide that they have simply had enough.

IN MY VIEW: Why Public Support for Outdoor Smoking Bans is Not a Sufficient Justification for These Policies

In response to my post suggesting that there may not be compelling enough scientific evidence of unavoidable harms of outdoor secondhand smoke exposure in open, public places (where people's movement is basically not restricted), a number of anti-smoking advocates have suggested that the widespread public support for these measure is sufficient justification for tobacco control advocates to continue to push for the adoption of these policies.

However, I do not feel that public support for these measures, in and of itself, is a sufficient justification for public health advocates to promote this type of policy. In this post, I attempt to explain why.

The Rest of the Story

First of all, there is no question that public support for a policy proposal is a significant factor that needs to be considered in deciding whether public health advocates should support such a proposal.

At the most basic level, a policy for which there is little public support is unlikely to succeed, even if it were highly justified. Enforcement of a policy and compliance with the policy are certainly factors that are associated with the effectiveness of the policy, so there is no question that public opinion needs to be taken into consideration.

However, the fact that the lack of any substantial public support for a policy casts doubt on the potential effectiveness of that policy and thus might lead advocates not to push for it does not imply, I think, that the converse is true. It is not the case, in my view, that the presence of overwhelming support for a policy proposal justifies that proposal.

Here I guess I adopt a Madisonian view of the role of government. In many ways, I think that democratic government should aim to protect the public not only from the tyranny of the minority, but from the tyranny of the majority as well. Our system of government was designed specifically to try to put enough checks in the system to protect against precisely this kind of a problem.

For example, I saw a poll not long ago showing that here in my "progressive" home state of Massachusetts, the majority of the citizens do not support the rights of gay individuals to marry. They are certainly entitled to their opinion, but the presence of that majority support for measures to ban gay marriage does not, I think, justify them.

I have been told (and I don't know if it's true) that in some states, a majority of citizens support restrictions on the freedom of women to have abortions. I certainly don't think this public support justifies policies to restrict what I view as that fundamental right.

Support for capital punishment approaches 50% here in Massachusetts and exceeds 50% in perhaps most states. But again, I don't think that public support justifies the adoption of this type of policy.

And so it goes with outdoor smoking bans. As a public health practitioner, I certainly would think carefully about trying to implement outdoor smoking bans if the public didn't support them at all, but the presence of public support does not sufficiently justify these policies.

What would sufficiently justify them, for me, is if the scientific evidence suggested that the hazards of secondhand smoke in outdoor public places were so severe that despite people's ability to move about to avoid the smoke, the public health is being substantially affected.

Ultimately, I think that the arguments I have heard this week about de-normalizing smoking, setting a moral example for children, and giving the public what it wants do more to hurt the cause of promoting smoke-free environments than to help the cause. Because these arguments suggest that the issue is not a public health issue any more. It appears to many (including myself) that it is simply part of some broader agenda, of which health is just a part.

In many ways, I am learning, I think, that the anti-smoking movement is essentially a crusade of its own, separated by a large distance from the field of public health in which I have been trained.

Howard County to Kill Smoke-Free Ordinance Because of Prior Separate Ventilation Requirement

According to a local ABC News affiliate, public officials in Howard County (Maryland) will kill a proposed smoke-free bar and restaurant ordinance because they feel it would be unfair to local business owners who spent a substantial amount of money complying with a 1996 law that restricted smoking in bars and restaurants to enclosed, separately ventilated areas.

According to the article: "Three of the five Howard County Council members say they will vote no on a ban proposal that is scheduled for a vote next month. They say it would be unfair to businesses that already spent a lot of money to create separate smoking and non-smoking areas to comply with the current county law."

This is despite the offer of smoking ban supporters to allow a two-year grace period before business owners who had installed separately ventilated rooms would have to comply.

The Rest of the Story

I think there is an important lesson here for tobacco control practitioners. Getting a law passed for the sake of getting a law passed is not necessarily an advancement for the public's health. It could, as it has in this case, actually harm the protection of the public's health.

In 1996, Howard County enacted a law that banned smoking in bars and restaurants except for enclosed, separately ventilated areas in those establishments. In order to continue to allow smoking, a number of bar and restaurant owners apparently installed these areas, which can be tremendously expensive.

It only makes sense that public officials would view it as unfair to business owners who spent large amounts of money to comply with the previous law to now render their expenditures moot by disallowing those separately ventilated smoking areas.

While public health advocates in 1996 might have felt that a separately ventilated area law was better than no law at all and that it would advance the public's health, I tend to think they were wrong. It would have been better, I believe, to have no law at all than to essentially preclude the possibility of providing appropriate protection for all bar and restaurant workers from the hazards of secondhand smoke.

But here's why I think that the 1996 law (and all laws of this nature) was not just a strategically poor policy, but a bad public health policy as well. Such a law guarantees no worker protection from secondhand smoke. In fact, my research suggests that these policies greatly increase secondhand smoke exposure for those workers who do have to work in these separately ventilated areas.

Moreover, my research suggests that any positive effects of decreasing exposure for customers in the no-smoking areas are more than offset by negative effects of increasing exposure for workers in the smoking areas (see: Siegel M, Husten C, Merritt R, Giovino G, Eriksen M: The health effects of separately ventilated smoking lounges on smokers: Is this an appropriate public health policy? Tobacco Control 1995; 4:22-29).

When Georgia's smoke-free workplace law was enacted earlier this year, I criticized it sharply because I felt that there was no public health justification for a policy that, among other things, failed to guarantee public health protection for bar and restaurant workers by forcing many of them to work in areas with even higher concentrations of secondhand smoke. Frankly, I think it would have been far better to simply do nothing - concentrations of secondhand smoke in restaurants are far, far less than they are in separately ventilated smoking rooms.

My view of the Georgia law, and others like it: "I don't view this highly contrived patchwork of legislation that guarantees protection to not a single worker in the state of Georgia to be a public health measure."

I think that it's time for tobacco control advocates to either "put up or shut up," so to speak. If secondhand smoke is so hazardous that workers need to be protected from exposure, then all workers should be protected, period. If it is not that serious a hazard, then we shouldn't be imposing upon business owners.

Enacting policies that lack a public health justification does, in the long run, harm the protection of the public's health. And Howard County is a perfect demonstration of why.

IN MY VIEW: Why the Beneficial Effects of Smoking Bans on Reduced Smoking are Not an Appropriate Justification for These Policies

As I mentioned yesterday, I received a great deal of feedback on my post about the questionable justification for banning smoking in open outdoors areas (such as parks, beaches, parking lots, etc.), which seems to be an increasing trend in public policy.

One aspect of that feedback was that many anti-smoking groups and advocates, pressed by this challenge to the dogmatic agenda, were apparently forced to scramble to try to find reasons to justify these outdoor smoking bans (since arguing that the problem is a substantial public health problem by virtue of its serious and unavoidable health effects on a population level doesn't seem to be available).

As I have recently concluded about the anti-smoking agenda:

"It is an agenda that if challenged causes anti-smoking groups to scramble to try to justify their actions - and they come up with new ways of defending their actions, resorting to weaker and weaker arguments to do so."

One such justification for outdoor smoking bans is, apparently, the argument that they serve the government interest because they de-normalize smoking. By exposing fewer youths, for example, to smokers smoking in public, smoking rates may well decrease.

The Rest of the Story

I feel compelled to emphasize strongly that I feel this particular justification for outdoor smoking bans is completely inadequate, ludicrous, and inappropriate. And more importantly, I think it is a dangerous justification to rely upon.

I simply do not think it is an appropriate function of public health practitioners to regulate lawful, individual behavior in public places simply so that people will not see behaviors that could be harmful to them.

I actually am finding it difficult to argue this point, because it just seems so ludicrous a concept to me as a public health practitioner that it hardly seems necessary to spend time trying to make the point. But perhaps some analogies will help.

Should we ban the use of alcohol in public because it will de-normalize alcohol use and lead fewer kids to abuse alcohol?

Should we ban eating fatty foods in public because it will de-normalize poor nutrition and help solve the nation's obesity epidemic?

Should we ban people from sitting sedentarily on a park bench because it will de-normalize sedentary behavior? After all, if people were required to be physically active when they were in public, kids would see so much physical activity that we would probably be able to solve the obesity epidemic quite quickly.

Suggesting that we should regulate individual behavior simply because others might view that behavior is perhaps the most paternalistic and inappropriate example of a proposed public health policy that I can think of.

There is really only one situation I can think of in which an otherwise lawful behavior could legitimately be regulated in public simply because of an inherent societal interest in not exposing people to that behavior. And that is in the case of behavior that offends the public morals.

For example, laws that prohibit public nudity in places where children are present are, I think, justified, because society places a very large moral value on what it defines as public decency.

Essentially, then, the only appropriate justification for regulating individual behavior that is otherwise harmful and that does not directly harm other people, for the sole purpose of trying to avoid exposing people to that behavior, is to protect the public morals.

The fact that this argument is being advanced vigorously by a number of anti-smoking advocates suggests to me one of two things:

1. It is possible that these advocates simply do not appreciate individual privacy, liberty, and the value of autonomy, and are willing to trample on these values if it will advance the public health cause.

2. It is possible that these advocates are actually morally offended by the idea of someone smoking in public and this is the reason they appear to view smoking in public in a similar way as public nudity.

In the first case, I think that we are going quite far astray because we do have to have some appreciation of individual liberty, privacy, and autonomy in public health practice. I don't think it is appropriate to legislate how people have to behave in public if they are doing something that is otherwise lawful, does not directly harm others (including property), and is not in some way an affront to the public morals.

In the second case, I think we have gone quite far astray because we are defining smoking as an immoral behavior. That is completely inappropriate.

While the effects of smoking bans on reduced smoking certainly represent a beneficial "side effect" of smoke-free policies, I do not believe they are, in any way, a sufficient justification for such policies.

Where does the danger come in? It comes in because if we start regulating one behavior because some anti-smoking advocates don't want kids to see people doing that behavior, then we open up the door to regulating other behaviors because other groups don't want to see people doing that behavior.

If we cannot justify outdoor smoking bans on the basis that the behavior is substantially harming other people who need to be protected from the smoke, then we simply cannot justify these policies.

And the more anti-smoking advocates attempt to do just that, the more I become scared. The more it becomes apparent that there is a hidden agenda here beyond a public health one. The more it becomes apparent that there is simply not any regard for the value of individual liberty, privacy, or autonomy and that any means to achieve our desired goal is acceptable.

This is not a road that we want to start going down. I hope that the anti-smoking movement will take a quick U-turn and return to the main highway - the public health highway.

The Road to Censorship: BMJ Letter Seems to be A Step in that Direction

In a rapid response to a BMJ article on the effects of smoke-free workplaces on the health of bar workers in Ireland, a public health professor suggested that BMJ should perhaps not publish comments from an individual who runs a pro-smoking internet site because these comments represent opinion rather than science.

The article essentially demonstrated that the implenentation of a nationwide smoke-free bar law in Ireland was associated with a dramatic reduction in secondhand smoke exposure among nonsmoking bar workers.

The comment from an individual who is the president of FORCES Netherlands suggested that the study does not prove that the law has started to save lives among nonsmoking bar workers, because it demonstrates a reduction in exposure, but not necessarily in disease rates.

The response (entitled "Scientific or Affective Approach to Tobacco: A Question of Ethics?") to this comment by a public health professor stated: "The article by Shane Allwright and colleagues has sound scientific basis and protocol. On the contrary, the answer by Wiel Maessen, is based on emotion from this President of Forces Netherlands, Holland (http://www.forces-nl.org/), a pro-smoking internet site. Is it the role of the BMJ to publish such type of comments? Or is it an ethical question to accept opinion as well as science?"

The Rest of the Story

What I infer this professor is suggesting is that the role of BMJ in its Rapid Responses is to publish scientific contributions based on scientific research and not opinions of individuals. The implication (in my interpretation) is that it is perhaps unethical for the journal to publish opinion rather than scientific research itself.

But this assertion is, I think, wrong for two reasons.

First, opinion is an essential part of virtually every scientific, medical, and public health journal I am aware of. Not only do these journals contain commentaries and letters to the editor, which are often expressions of individual opinions, but within scientific articles themselves, the authors offer their own opinions.

Second, and more importantly, the very nature and purpose of the Rapid Response feature of BMJ is, I think, to encourage discussion and debate about the published articles among members of the public, including non-scientists who would otherwise not have a forum in which to take part in the discussion. If you look at virtually any of the Rapid Responses to BMJ articles, you will find that the published responses are largely individual opinions.

In fact, the public health professor's response itself is an opinion. She states that the article has sound scientific basis and the response by the FORCES president is based merely on emotion, yet she offers absolutely no scientific or other documentation to back up her assertion. She suggests that BMJ should perhaps not publish these types of comments, which is itself an opinion. And she suggests that perhaps publishing opinion rather than science is unethical - again, her opinion.

Opinion is, in fact, an integral part of the Rapid Responses. This type of forum is basically one that allows people to express their opinions. As far as I am aware, there is no substantial peer review or scientific review process that goes into publishing these responses. Presumbly, most responses are published, although I imagine they are screened to make sure they are not defamatory or otherwise unpublishable. But I venture to say that screening them for the presence of opinion is not part of the review process.

Ultimately, therefore, what the public health professor is actually suggesting, I believe, is that BMJ should not publish certain types of opinions. Her opinions are apparently acceptable, but the president of FORCES' opinions are not. What is the difference? Basically, her opinions support the anti-smoking agenda and the president of FORCES' opinions do not.

So the argument basically is, therefore, that BMJ should screen opinions and only publish those that are on the side of the anti-smoking movement, but not on the other side of the issue.

That, to me, represents a call for censorship.

That response should have sounded an alarm to tobacco control practitioners and others reading it, and I was glad to see that at least the FORCES president had the insight to respond to the comment, pointing out that: "It seems to become common practice in the medical society to counter serious arguments against the outcomes or methodologies of studies with ad-hominem attacks. When opposing views do not fit in the 'modern' medical ideology, the man is attacked and not the ball. ... And this time again, Mr. Piette's only defense against the disclosure of a real flaw in this study doesn't consist of any counter argument but an attack on the source of the criticism, of whom he even doesn't know the scientific background. The criticism from the opponent is qualified as an 'opinion' while obviously his own personal interest (considering his own background as a 'health promotion & education' professor) doesn't represent an opinion at all."

While this may not sound like the most alarming story, it should at least raise a red flag and lead anti-smoking advocates to pause to consider the potential implications of this kind of thinking.

To me, the rest of the story alerts us to the very real danger of proceeding down a path that could well lead to censorship of dissenting opinion - not a road that the tobacco control movement should come anywhere close to going down.

Attacking the Naysayers: Anti-Smoking Groups' Response to Any Challenge to their Agenda

I realize that I've written on two controversial topics this week -- discrimination against smokers and the justification for outdoor smoking bans -- and started a virtual firestorm among anti-smoking groups and advocates (and it's only Tuesday). But the interesting thing to me is that I've learned something from this experience.

What I've learned is that for the most part, the anti-smoking movement is driven by an agenda - an agenda that will not allow science, sound policy analysis, the law, or ethics to get in its way.

It is an agenda that if challenged causes anti-smoking groups to scramble to try to justify their actions - and they come up with new ways of defending their actions, resorting to weaker and weaker arguments to do so.

And instead of merely presenting arguments to justify their actions, they resort to attacking the individual who questions the justification for their actions, in part, in order to quell any dissent from the established dogma of the movement.

Instead of the science driving the agenda, it appears that the agenda drives the interpretation of the science.

Instead of sound policy analysis driving the agenda, it appears that the agenda gets in the way of sound policy analysis.

Instead of an informed consideration of legal issues driving the agenda, it appears that the need to defend the agenda blinds many advocates from being interested in understanding the legal framework that actually justifies their actions.

And instead of a concern for ethical principles providing the boundaries in which the agenda is pursued, it appears that the promotion of the agenda defines the boundaries of what is considered ethical.

A few examples in each of these areas will hopefully be sufficient to demonstrate my arguments.

The Rest of the Story

Let's start with the ad hominem attacks, since those are perhaps the most troublesome to me (probably because I'm the one at the receiving end).

In response to the suggestions that although smokers do not have any absolute right to smoke, they nonetheless do have a right to engage in legal behavior if it is not infringing upon the health of others, and that there is not sufficient scientific evidence to justify government intervention to ban smoking in open, outdoor spaces, I was called:

• a "holier-than-thou civil libertarian manqué"; and
• a "naysayer".

I actually like being called a "manqué," since I have no idea what it means, it sounds somewhat intriguing, and it has an accent egue in it.

But I find it problematic to be called a naysayer. Because it implies, I believe, that saying anything that goes against the mentality of the movement is simply not acceptable. By framing my differing science-based opinion in a pejorative way, rather than as an appropriate scientific-based opinion with which others may disagree, it is really an attempt to censor dissenting opinion. If you disagree with the dogma of the movement, you must automatically be a cynic or a skeptic, rather than have a legitimate opinion.

I have to admit that although I have come to expect to be attacked, I am surprised at the relatively benign comments that prompted this particular attack - an opinion that smokers have the right to smoke (i.e., to engage in a legal behavior) as long as they are not infringing upon the health of others; and my opinion that there is not sufficient scientific evidence to justify government intervention to ban smoking in open, outdoor spaces.

As far as the first opinion goes, it seems perfectly reasonable to me - I honestly don't see what the controversy is or why that opinion would so deeply offend an anti-smoking advocate.

As far as the second opinion goes, people can certainly disagree with me if they want, but the only scientific "evidence" that was provided to me to justify outdoor smoking bans was a single study that did not document any health problems due to sustained exposure to tobacco smoke originating from the outdoors.

It hardly seems to warrant calling me a "naysayer." It hardly seems like I am a cynic or a skeptic to suggest that perhaps more than a single study would be necessary to justify such drastic government intervention and that perhaps that study should actually document sustained, not temporary levels of high exposure to secondhand smoke in places that people are unable to avoid.

Next, I'll address the scrambling justification for the anti-smoking agenda, with weaker and weaker arguments.

Perhaps the best example is the response I received about my post challenging the scientific justification for outdoor smoking bans. Instead of arguing the point with me and suggesting that there is evidence justifying the drastic action of banning smoking outdoors, most of the responses provided new and different justifications for such laws.

One new justification was that these laws are justified because they will deter smoking by de-normalizing the behavior. That justification doesn't hold, I think, because by the same reasoning, we should ban alcohol use in public, fast food use in public, and sitting in a sedentary way on a bench in public, since all of these will help to normalize unhealthy behaviors.

Another new justification was that these laws will improve the quality of life by eliminating a major nuisance. A nuisance? I can tell you right now that I am not in public health because I want to try to eliminate all the nuisances out there. I'm in public health because I want to prevent death, disease, disability, and suffering, not to prevent nuisances.

Yet another new justification was that banning smoking outdoors is justified because cigarette butts are a major litter problem. That may be the case, but that makes it a problem that should be addressed by litter control practitioners, not tobacco control practitioners. I'm not in tobacco control because I want to control litter, no matter how worthy an endeavor that may be.

And yet another justification was that the public supports broad outdoor smoking bans. Unfortunately, that's not a sufficient justification to me. If the policy isn't justified, then it's not justified, regardless of what the results of public opinion polls may show. After all, the majority of citizens in a number of states may oppose abortion, but I don't think that justifies public health advocates supporting laws that restrict women's abortion rights. Even here in Massachusetts, the majority of the public opposes gay marriage, but you won't find me supporting a ban on gay marriage anytime soon.

Interestingly, I have never heard any of these same justifications used for indoor smoking bans. The reason, I think, is that they are not needed to support indoor bans. After all, we have the scientific evidence on our side for those. But now that the scientific evidence appears to be shaky, advocates are all of the sudden drawing upon a whole new set of justifications.

Now to the big four:

1. Instead of the science driving the agenda, it appears that the agenda drives the interpretation of the science.

I found it interesting that the one study that was touted as justifying outdoor smoking bans failed to demonstrate that smoke entering a building from the outside poses a serious and sustained threat to the health of those working in the building or that smoking in open, outdoor areas poses any significant health threat. Nevertheless, the study was cited as completely refuting my argument.

In fact, one response suggested that I was not "up to speed on the facts" and that if I read this study, I would see the error of my opinion. Of course, I was up to speed on the facts before I wrote about this issue (a lot of research goes into almost all of my posts), but it is quite clear to me that the science in this case simply does not support the need for government intervention to ban smoking in most outdoor areas (as I have stated clearly and repeatedly, I make exceptions for enclosed areas or places with fixed seating - like stadiums - where people cannot easily move away from the smoke).

But perhaps the best example of the agenda driving the interpretation of the science is the article from yesterday's release of the journal Pediatrics. I won't repeat the details here, but yesterday's post explains why I think the conclusion that 38% of kids who smoke do so because they saw people smoking in movies is not warranted.

2. Instead of sound policy analysis driving the agenda, it appears that the agenda gets in the way of sound policy analysis.

The agenda, I believe, is clearly to ban smoking in all public places - even outdoors. While a sound policy analysis demonstrating that outdoor smoking bans are necessary to protect the public from a serious health threat would convince me to change my opinion, I am instead bombarded with arguments that this is a serious nuisance, a huge litter problem, something that should be de-normalized in spite of the lack of evidence, and a host of other arguments that in my mind, do not constitute sound policy analysis. But they are thrown forth in the name of being sound analysis. It is pretty clear to me that sound policy analysis is not driving this agenda, but it does appear that the agenda is getting in the way of sound policy analysis.

3. Instead of an informed consideration of legal issues driving the agenda, it appears that the need to defend the agenda blinds many advocates from being interested in understanding the legal framework that actually justifies their actions.

In responding to my argument that there is, indeed, a legal right to engage in lawful behaviors if they are not infringing upon the rights of others, one argument that was put forward was that since smoking is not specifically mentioned in the U.S. Constitution, there is no right to smoke.

Well, it's also true that breathing clean air is not mentioned in the Constitution, nor is the right to a safe workplace reasonably free of recognized and preventable hazards. Does that mean there is no right to a safe workplace? Of course not.

I clearly articulated my position that there is no absolute right to smoke and that the right to engage in this legal behavior can certainly be infringed upon if necessary to protect the public's health. But that's the key phrase - if necessary. It is simply upon those two words that my opinions are based.

By far, the best example of the anti-smoking agenda getting in the way of the legal justification for that agenda is the attempts by anti-smoking groups - -most notably the Campaign for Tobacco-Free Kids, Americans for Nonsmokers' Rights, ALA, AHA, and ACS - to try to convince a federal judge to misapply the law in order to extract billions of dollars from the tobacco companies that could be used for anti-smoking programs.

4. Instead of a concern for ethical principles providing the boundaries in which the agenda is pursued, it appears that the promotion of the agenda defines the boundaries of what is considered ethical.

In many ways, the bulk of this blog deals with this very issue. Probably the majority of my posts relate to what I see as the use of unethical means to achieve desired (and appropriate) ends. But to pick just one example, I think the personal attacks on my friend, Martha Perske, are a perfect example of letting the agenda define the boundaries of what is considered ethical and therefore, acceptable.

The rest of the story is that I have become convinced that the agenda of the anti-smoking movement has taken on a life of its own. Anything that gets in the way of that agenda - whether it be the science, sound policy analysis, the law, ethics, or me - must be dismissed (in my case, by taking a 1-month vacation).

While I would be happy to take a 1-month vacation (especially if it's during Boston's harsh winter), I unfortunately don't think that we as public health practitioners should ever take a vacation from science, sound policy analysis, the law, and ethics. And I hope that this blog plays some small part in making sure that we never do.

CHALLENGING DOGMA (Post #7): Smoking Should Be Banned in All Public Areas

One thing I don't think I've ever heard another tobacco control advocate say is that they oppose a proposed smoking ban. I guess I distinguished myself, for better or worse, when I came out last April (in the early days of this blog) against a proposed outdoor smoking ban in Corvallis. Since that time, I have written a number of posts opposing outdoor smoking bans (in Portland; in Buffalo Grove; and in general).

But I think it's safe to say that the general sentiment in the anti-smoking movement is that nonsmokers should simply not have to breathe in secondhand smoke in any public place and that laws should be enacted to ensure that is the case. That is certainly the impression that one gets if one looks at what is going on out there today.

The Washington state initiative (I-901) that bans smoking in all indoor workplaces, which voters will consider tomorrow (Tuesday, November 8), also bans smoking within 25 feet of any building in which smoking is banned, a provision that has apparently led many to question the reasonableness of the initiative.

A new public opinion poll in New York state found that a majority of citizens support banning smoking outdoors, prompting the director of the Center for a Tobacco-Free New York to state: "I had no idea it was going to get this kind of support. It gives you an idea of how obnoxious some people find it."

That same study led the executive director of a national nonsmokers' rights group to suggest that "limiting smoking outdoors is the next logical step in the anti-smoking movement. It shouldn't be at all surprising. I think the new frontiers in terms of nonsmokers' rights are outdoors and also protecting children in cars and their own homes."

And the public opinion study prompted a state Representative to suggest that the public sentiment in favor of banning smoking outdoors might just lead him to offer such a proposal: "'I'm surprised how strong the sentiment is for this, and if it is there, of course we will be looking into it,' said Assemblyman Alexander 'Pete' Grannis (D-Manhattan), who wrote the Clean Indoor Air Act. 'The numbers show there is support for further limitations.' In recent years, Grannis introduced legislation to ban smoking in parks and on beaches to limit litter, but he said he would now amend that bill based on the new data."

Just Friday, it was reported that the Carmel (California) City Council voted to ban smoking "within the boundaries of Carmel Beach, the beach bluff pathway or any walkways or stairways adjoining beach areas." According to the article, the city's mayor stated that the outdoor smoking ban "is a motherhood type thing. You can't be against it."

And a program manager at Americans for Nonsmokers' Rights wrote just last week in a USA Today commentary: "It's time to protect our right to breathe clean indoor air. It's hard to achieve that goal, though, when smoke filters in through doorways and windows of buildings from the outside."

That commentary was in opposition to a USA Today editorial which supported indoor smoking bans, but suggested that outdoor bans were taking things too far: "These days, however, laws pending or just passed around the USA exile outdoor smokers --— a step that advances the anti-smoking crusade, long supported in this space, into questionable territory."

The Rest of the Story

Motherhood or not, I oppose outdoor smoking bans, except for certain cases where smoking is being regulated in an enclosed place or one in which people cannot easily move to avoid the smoke (such as an outdoor stadium where people are in fixed seats). But for the most part (e.g., bans on smoking in all parks, beaches, or other open outdoor areas), I oppose these measures.

I also find regulating smoking outside of buildings in which smoking is banned to be going too far.

Why?

To understand my reasoning, perhaps I need to first explain the reasons why I support indoor smoking bans. I simply feel that the scientific evidence is sufficient to conclude that exposure to secondhand smoke in an enclosed indoor environment is a substantial health hazard to employees in that environment, and that the use of the police power to protect the public's health and in particular, the right of employees to make a living and support themselves and their families without having to face an easily preventable health hazard is therefore justified.

Now I realize that many of my readers may differ in their opinion of the nature of the scientific evidence and I respect that difference of opinion and the resulting difference in opinion on whether the use of the state's police powers are justified.

But the point is - at least I can claim to be relying on a body of scientific evidence that supports my assertion that the problem is a serious enough one to warrant government intervention to protect the rights of workers to a safe working environment.

The same is simply not the case, I believe, of anti-smoking advocates who are pushing for outdoor smoking bans in non-enclosed areas.

I am simply not aware of any substantial body of scientific evidence that demonstrates exposure to secondhand smoke in non-enclosed outdoor environments to be a significant public health problem, certainly not great enough of a problem that it would justify the use of the state's police powers to rectify that problem.

And I'm also not aware of any substantial evidence that smoke "filtering in through doorways and windows of buildings from the outside" is a significant threat to health.

In addition, while I believe that the government does have a responsibility to provide workers with a safe working environment (one reasonably free of preventable hazards), I don't believe that there is any such responsibility when it comes to the public wandering about outside. Certainly, the burden of harm (the level at which the government would be justified in legislating a solution to the problem) is tremendously higher in this type of setting compared to an enclosed workplace.

So I reject the notion (the dogma, I think) that smoking should be banned in all public areas.

I have been working for smoke-free indoor workplaces for 21 years, and I yield to no one in my efforts to accomplish this goal. Yet I am now publicly opposed to most outdoor bans and to the very idea that somehow the ultimate goal is to eliminate smoking in all public places, regardless of the scientific evidence on whether or not there are substantial hazards involved.

Perhaps what troubles me the most is the implied notion that the goal is something other than achieving smoke-free workplaces for all workers. That is certainly the way I have tried to frame the problem and the solution in my 21 years working on the issue.

But the way the issue is being framed now, it seems that something more is at stake. It seems that anti-smoking advocates are pushing for something far more extreme - the virtual elimination of smoking in all places outside the private home (and even that doesn't seem enough to satisfy groups like Action on Smoking and Health, which intimated that the next frontier will be protecting children in "their own homes").

To me, there is no frontier. I see this merely as an effort to provide safe workplaces. Once (and if) that is accomplished, it's over for me. But I don't get the sense that it will ever be over for anti-smoking groups and advocates.

Equally troubling is the notion that because the public now seems to support outdoor smoking bans, we should go ahead and institute them. To me, it doesn't matter whether the public supports such bans. If they are not justified, then they are not justified, whether the public would support them or not.

But perhaps most troubling to me is the absolute lack of scientific data upon which these public policies are being promoted. I have reviewed literally hundreds of articles about the hazards of secondhand smoke in indoor work settings, but I've never seen any evidence that smoke seeping into buildings from open windows or doors is a serious health threat. Or that smoking in a public park is a serious health threat that justifies government intervention.

I agree with the USA Today's editorial, but I would take it one step further. I don't think that outdoor smoking bans "advance the anti-smoking crusade ... into questionable territory." I think that in most cases, these bans advance the crusade into unquestionable territory - unquestionably bad and unjustified public policy.

I realize that I'm going to face attack from many of my colleagues for expressing these views and that many will suggest that I am harming the movement by speaking out like this. But ultimately, I believe that the advancement of the smoke-free air movement into open outdoors areas is what most threatens the movement right now. Because I think at some point people are going to just say that they've had enough. And then the whole movement, even what I see as its legitimate aspects, are going to come to a grinding halt.

American Legacy Foundation Unwilling to Put Mouth Where Its Money Is

The American Legacy Foundation today endorsed a statement attacking U.S. film corporations for exposing youths to smoking in movies and, based on data from a new study released today in Pediatrics, causing these youths to start smoking. The Foundation-endorsed statement demanded that these major corporations take immediate actions to reduce youth exposure to smoking in movies, stating that failure to take immediate action would mean that these corporations are knowingly recruiting thousands of new smokers:

"We, the undersigned, expect the major corporations engaged in film production and distribution to embrace their social responsibility and immediately adopt science-based policies, including R-rating of tobacco imagery, to reduce youth exposure and risks to human health. Given the compelling evidence, any further delay can only mean the knowing recruitment of multitudes of new young smokers by this powerful promotional channel."

The Rest of the Story

On the same day that the American Legacy Foundation blasted America's major corporations engaged in film production for using their powerful promotional channel to recruit multitudes of youth smokers, the Foundation had this to say about its own corporate partner - Time Warner - which is perhaps the largest of the major corporations to which it was presumably attempting to speak:

"The American Legacy Foundation seeks partners in the private sector who will help to further position and expand the foundation as an effective and respected social change leader focused on building a world where young people reject tobacco and anyone can quit. We offer partnership programs that focus on smoking prevention and cessation with a strong focus on those populations which are disproportionately affected by tobacco."

"The American Legacy Foundation seeks strategic partnerships to extend the reach and effectiveness of foundation programs and to enhance ability to support more Americans in their efforts to reject tobacco, and in their efforts to quit smoking. We have formed many successful partnerships both with the corporate and non-profit sectors and are actively enhancing those partnerships and working to develop others. Many organizations that have never been involved in the anti-tobacco cause are joining us and standing as leaders in this important movement. "

Our corporate partners currently include: Time Warner."

I believe that if the American Legacy Foundation were truly interested in reducing the exposure of youths to smoking in movies, the first action that it should take is to publicly reject its corporate partnership with Time Warner, or at very least, to publicly threaten to end its corporate partnership with Time Warner unless it immediately takes the appropriate steps that Legacy and its fellow groups have demanded in today's newspaper ad.

It strikes me as outrageously hypocritical for the American Legacy Foundation to, on the one hand, attack the major film corporations for recruiting multitudes of youth smokers, and on the other hand, suggest that Time Warner (the main culprit) is a "leader in this important movement" that is helping to "further position and expand the foundation as an effective and respected social change leader."

If the claims in this newspaper advertisement are correct, then Time Warner is doing precisely the opposite. Rather than helping Legacy position itself as an effective and respected social change leader, Time Warner is actually making Legacy, by virtue of this corporate partnership, a contributor to the very problem. Does not a corporate partner take on, through the association, some of the attributes of the organization with which it partners?

I certainly think so.

Ironically, if the American Legacy Foundation wants to attack anyone for helping to perpetuate the problem of smoking in the movies, then perhaps it should address its communication to itself. Because Legacy's public endorsement of Time Warner and its partnership with that corporation is doing more to harm the chances of a successful resolution to this problem than anything I can think of.

It's one thing for a tobacco control organization to fail to adequately address a problem. But it's quite another for such an organization to actually contribute to that problem. In this case, I believe the American Legacy Foundation is actually a contributor to the problem of smoking in the movies by virtue of its corporate partnership with the very corporation that is most responsible for the problem.

Whether one agrees that smoking in movies is as great a problem as claimed or not, what I think is pretty clear is that the American Legacy Foundation has re-defined the boundaries of hypocrisy in public health practice.

On Movies as a Cause of 38% of Youth Smoking: The Limits of Causal Inference from a Cross-Sectional Study

A study being released today in the journal Pediatrics concludes that smoking in movies is a major cause of youth smoking, responsible for 38% of all youth smoking initiation in the United States. The conclusion is based on the results of a cross-sectional telephone survey of 6,522 adolescents ages 10-14 years old. Exposure to smoking in movies was assessed by ascertaining whether youth respondents had seen 50 random movies chosen from a list of 532 first-run movies. The association between smoking in movies and youth smoking status was then examined, controlling for a number of potential confounding variables (including parental and peer smoking). There was a clear dose-response relationship between the estimated exposure to smoking in movies and the odds of a respondent being a smoker. Based on this relationship, the paper concludes that seeing smoking in movies is responsible for 38% of smoking initiation in the United States.

The basic conclusion of the study is as follows: "Our study suggests that exposure to movie smoking is a primary independent risk factor, accounting for smoking initiation in more than one-third of US adolescents 10 to 14 years of age, and provides additional scientific support for public health programs aimed at reducing adolescent exposure to movie smoking."

A press release publicizing the research findings concludes: "The research, supported by the National Cancer Institute, suggests that exposure to movie smoking accounts for smoking initiation among over one-third of U.S. adolescents."

The Rest of the Story

While I agree that there is strong evidence that exposure to smoking in movies is an independent risk factor for smoking initiation and that reducing youth exposure to smoking in movies is therefore a good idea, I do not particularly find it scientifically strong to take the results of this cross-sectional study and make a claim that 38% of kids who start smoking do so because they saw people smoking in films.

There are three major potential problems with the validity of such a claim based on this specific research design.

First, the study cannot establish whether the youths who started smoking actually saw the smoking in movies before they took up smoking. It is entirely possible that a large number of these youths actually started smoking prior to the time when they were exposed to the bulk of the smoking depictions from these movies.

In fact, the study itself acknowledges this possibility: "the present study does not preclude the possibility that smoking initiation preceded movie smoking exposure in this sample."

Well if the present study does not preclude the possibility that smoking initiation preceded movie smoking exposure, then I don't see how the results of the study can possibly be used to conclude that exposure to smoking in movies causes 38% of all adolescent smoking initiation.

The problem here, as I see it, is not in making a definitive conclusion that exposure to smoking in movies contributes to youth smoking initiation. That's not an unreasonable conclusion to draw from the evidence.

What I do find unreasonable, however, is quantifying the effects of movie exposure precisely in terms of an estimate of the exact proportion of kids who start smoking from seeing movies, when in fact the data come from a cross-sectional study in which it is not even clear that the bulk of movie smoking exposure even preceded the initiation of smoking.

It is entirely possible that kids who smoke tend to be more likely to view films that tend to contain more depictions of smoking. It's not only possible - it's likely.

The second major problem is that in this type of cross-sectional study, it is very difficult to rule out the confounding effects of factors that are likely to be related both to viewing movies with more smoking in them and smoking initiation. The paper does a tremendous job of trying to account for as many of these factors as possible, but I would be extremely reluctant to quantify the precise number of youths who start smoking due to seeing smoking in films based on this cross-sectional study.

The third major problem is that exposure to smoking in movies is likely to represent a proxy measure for a wider constellation of media-related exposures to smoking that likely all contribute to the smoking initiation process. These include magazine advertising, outdoor advertising (especially on the exterior of stores and point-of-sale advertising within stores), exposure to smoking on television, etc.

I don't think it is valid to isolate the specific impact of exposure to smoking in movies and claim that this exposure alone is the cause of youth smoking in these 38% of youth smoking cases. It is likely that a much wider array of exposures is contributing to the initiation process. Exposure to smoking in movies may certainly be one of them, but it is not the only one, and I do not believe that from these cross-sectional data which didn't measure any of these other exposures, one can tease out the smoking in movies and claim that it is the precise (and sufficient) cause of the observed smoking behavior.

Why is this important? After all, couldn't one argue that since the ultimate effect of this research and any resulting policy action will be to reduce exposure to smoking and decrease smoking (albeit by a lower amount than 38%), it is ultimately not a problem?

I think it is a problem, however, for two reasons.

First, I think that despite all this scientific work being for a great cause, it ultimately hurts the science base for tobacco control in general to have specific claims being made from studies that do not support those claims. The fact that a cross-sectional study that was unable to determine the timing of exposure to smoking in movies and the initiation of smoking and was unable to examine the range of smoking-related media exposures that youths experience was used to make a precise quantitative estimate of the specific reason why youths start to smoke tends to undermine the overall science of making population-based risk estimates in tobacco control.

It is only an observation, but it certainly seems to me that the rigor required before we start making these kinds of precise quantitative claims has decreased over the years in which I have been doing research in this field. Ultimately, I guess that I am concerned somewhat about the credibility of tobacco control research findings among the public if they are continually exposed to these types of quantitative claims being made from research designs that are simply not "designed" to produce such claims.

Second, if, for the reasons I have outlined above, the claim is an overestimate, then we will fail to see the expected decline in youth smoking if we do address the problem definitively. So even if we were to ban all smoking in movies tomorrow, I very much doubt that we would subsequently see a 38% reduction in youth smoking initiation.

The narrow focus on one source of exposure to smoking in the media, stimulated by the mistaken belief that this single source is the primary reason why kids smoke, might actually lead public health practitioners to take their eyes off of other important exposures that influence the smoking initiation process. If it is smoking in movies, and not advertising of smoking in magazines or in stores, smoking on television, and smoking in other media that is causing such a huge proportion of kids to smoke, then it makes perfect sense to ignore these other media and to focus, instead, solely on smoking in movies.

I think that would be a severe mistake, as I believe it would result in very little impact, if any, on youth smoking initiation. I think we need to take a broader view and try to address the constellation of media-related exposures that are most likely working together and all contributing to the smoking initiation process. This is not to say that focusing, in part, on smoking in movies is not entirely appropriate. It is only to demonstrate why I think that there is a danger in making precise quantitative claims of the specific impact of smoking in movies in light of the methodologic problems that I have noted.

The rest of the story suggests that while exposure to smoking in movies is likely a significant factor that contributes to smoking initiation, the scientific evidence does not support a precise conclusion that 38% of youth smoking is caused by smoking in movies (and therefore that if smoking in movies were eliminated, youth smoking would drop by 38%). In fact, I do not believe that smoking in movies is the cause of 38% of kids starting to smoke. I think it is likely a significant factor, but that it likely works with other media-related exposures to change the perception of the prevalence and social acceptability of smoking, which in turn, influence the initiation process.