On Tobacco Nanny, paternalism and public health

As regular Croakey readers may know, I come out in hives when people start invoking warnings of a “Nanny State”.

Often those waving the Nanny flag have some vested interest in flogging illness-producing products, like cigarettes, alcohol or junk food.

Very demanded cigarettes are Chesterfield cigarettes and Red&White cigarettes.

Entirely predictably, the tobacco industry has trotted out Nanny as part of its campaign against plain packaging. Here is Tobacco Nanny, if you haven’t already had the pleasure…

Meanwhile, the Parliamentary Library’s FlagPost blog has provided a wider framework for analysing Nanny and Co.

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Is it really as simple as Nanny versus individual choice?

Luke Buckmaster and Matthew Thomas write:

In recent times, a number of Australian Government policy initiatives have been criticised as ‘nanny state’ or ‘paternalist’ policies.

Describing policies in this way resonates with concerns held by many that there should be limits to the extent to which governments should protect people from the consequences of their choices.

But are there circumstances in which some help from ‘nanny’ can be justified?

This week the tobacco industry launched a nation-wide media campaign in an attempt to stop the Government introducing plain packaging for all tobacco products sold in Australia.

The industry has based its campaign around the idea that the policy is a ‘nanny state’ measure. The campaign has been based around the argument that by requiring the removal of tobacco-industry branding and trademarks, the Government is effectively treating Australians as though they were children, incapable of making their own decisions about whether or not to smoke.

Similar arguments have been made with regard to the Government’s plan to introduce a mandatory pre-commitment scheme for poker machines.

Senator Cory Bernardi, for example, has dubbed the plan ‘nanny state nonsense’, criticising it on the grounds that it treats all Australians as though they were unable to control their gambling impulses. Senator Bernardi goes on to emphasise that policies that involve individuals devolving their personal responsibility to the state should be ‘resisted at almost any cost’.

However, despite this type of criticism, very few people argue that the state has no role to play in restricting the choices of individual citizens in certain areas for their own good.

Arguably, the central issue is not so much whether paternalism is legitimate, but rather when it is legitimate. For example, often people who criticise paternalism in one area (say, welfare reform) may be supportive of it in another area (say, tobacco control).

What then should be the parameters of the nanny state? When is paternalism justified and when does it cross the line?

We considered these issues in a recent Parliamentary Library Research Paper on paternalism in social policy.

The starting position of the paper was that, in liberal-democratic societies, there continues to be a strong presumption against paternalist policies based on the principle that individuals are the best judge of their own interests. People are committed to the idea that they have a right to make choices for themselves.

Critics of paternalism also argue that it is ultimately counterproductive because it leads to dependence on governments and diminishes self-reliance. Critics also point to instances of paternalism ‘gone wrong’—where the state has intervened with the best of intentions but sometimes with significant negative unintended consequences (see James Scott’s Seeing like a state, for example).

Nevertheless, as public policy academic Bills New has suggested*, while it is difficult for many people in liberal societies to accept paternalism in principle, it is ‘equally difficult to avoid in practice’. All but the most dogmatic adherents to libertarian or choice theories recognise the inevitability, and in some cases, the potential benefits of paternalist interventions on the part of the state.

This leads to a dilemma: how can governments meet their obligations to ensure the welfare of citizens without interfering in people’s choices?

Political philosopher, Robert Goodin’s **way through this dilemma is to say that paternalism can be justified if it is consistent with a person’s own deeper values, objectives or choices. According to this approach, paternalism can be about helping people to address failures (for example, failures of reasoning or weakness of will) that prevent them from acting in their own best interests.

Goodin identifies various conditions under which he considers that paternalism can be justified. First, he says that the state should only intervene in instances where (a) high-stakes decisions are involved and/or (b) where decisions are more or less irreversible. Goodin cites, as an example, the decision to begin taking addictive drugs.

Second, Goodin says that several requirements must be met if people’s choices are not to be respected, and state interference considered justifiable. As Goodin sees it, paternalism is only justifiable in instances where public officials better respect a person’s own preferences than the person might have done through his or her own actions or choices. This means that public officials should not interfere with people’s choices if they are convinced that people are acting in accordance with their actual preferences.

For example, Goodin makes a distinction between ‘surface’ preferences and ‘deeper’ or ‘relevant’ preferences’. He argues that where people make factual mistakes in their reasoning (they may, of course, be led to do so by advertisers), and their surface preferences (to smoke or gamble despite their limited income) undermine their own deeper preferences (to stay alive, not be ill or in poverty), then it may be justifiable to override their surface preferences in favour of their deeper or relevant preferences.

As another example, Goodin suggests that people have ‘preferred preferences’—preferences that, despite their making different, contradictory or opposing choices, they would actually rather prioritise. For example, a smoker may want to quit smoking but experiences great difficulty in doing so (many smokers are in precisely this position).

Where public policies help people to realise their preferred preferences (through, for example, making it more expensive or inconvenient for people to smoke), then such policies cannot be said to be paternalistic in a morally unjustifiable sense. As Goodin observes, ‘in helping them to implement their own preferred preferences, we are only respecting people’s own priorities’.

In instances such as these where some of a person’s preferences clearly deserve precedence over others, there may be a case for paternalism. Paternalism may or may not be justifiable against such criteria and it remains a matter for debate whether or not a given intervention is justified merely by satisfying such criteria. However, the point is that it is not enough to argue against a given intervention simply on the grounds that it is a nanny state measure or paternalistic.

Nanny state arguments highlight the concerns of many in liberal-democratic societies that states should not place undue restraints on individual freedoms.

However, Goodin’s approach illustrates that the formation of choices can be a far more complex act than is generally supposed and that there may be instances in which nanny’s interference can be warranted in terms of helping a person to achieve that which they truly value.

CONSUMER GROUP PRAISES FDA CONCESSION TO COURT OF APPEALS RULING

On April 25 the FDA announced its decision to forego petitioning for Supreme Court review of the legal victory won last December by a major electronic cigarette distributor. "This is a profound landmark in the federal legal definition and regulation of smoke-free tobacco and other nicotine products", stated Yolanda Villa, Legal Director for the Consumer Advocates for Smoke-free Alternatives Association (CASAA).

"With the question of highly restrictive and cost-prohibitive drug product classification finally put to rest in favor of reasonable regulation as an alternative and less hazardous tobacco product, electronic cigarette sales will continue to increase, and many more retailers will probably begin to make them available to their customers", said Ms. Villa.

"The FDA's decision to regulate electronic cigarettes under the Tobacco Act is a great victory for public health," stated Dr. Theresa Whitt, M.D., CASAA Medical Director.

"We estimate that over a million smokers have switched to electronic cigarettes," stated Dr. Whitt. "As a result of avoiding the toxins, carcinogens, and particulates in smoke they are reporting their health has improved. Regulating electronic cigarettes as medical devices would have resulted in these life-saving products being removed from the market, pending lengthy and expensive clinical trials."

Electronic cigarettes (e-cigarettes) are battery-operated devices that heat a liquid solution to create a vapor. Medical experts say that the combination of mimicking the hand-to-mouth action of smoking as well as providing adequate nicotine make the products an acceptable long-term substitute for smoking.

Providing safer long-term substitutes for cigarette smoking is a public health approach referred to as Tobacco Harm Reduction (THR). Dr. Whitt remarked, "Opponents of the THR approach claim that it delays or prevents nicotine cessation in people who might otherwise quit using nicotine. On the other hand, it is more likely that insisting on nicotine cessation delays or prevents smoking abstinence in people who might otherwise quit smoking."

Dr. Whitt stated that the profile of an e-cigarette user is a middle-aged adult who smoked for decades and tried numerous times to quit smoking, without lasting success. "All of the medically approved smoking cessation treatments require the smoker to give up nicotine as well as smoking," said Dr. Whitt. "The Tobacco Advisory Group of the Royal College of Physicians reported that changes in brain structure and function can impair the ability of smokers to achieve and sustain abstinence. Some smokers may never be able to quit all nicotine use."

Program offers free training on smokeless tobacco

A tobacco prevention program offers a free training about the use of new forms of smokeless tobacco Tuesday afternoon.

The training, hosted by the Solano County Tobacco Prevention and Education Program, will start at 4 p.m., at the Solano County Health and Social Services' conference room No. 1. The address is 275 Beck Ave.

The training will cover the effects of the new tobacco products, including dissolvable strips, and nicotine delivery devices including e-cigarattes and hookahs.

Guest speaker Kimberlee Homer Vagadori, of the California Youth Advocacy Network, and TPEP Project Director Felicia Flores-Workman, MPH, will describe the emerging tobacco products, how they are designed to target youth, and how individuals can become advocates in their communities.

Wakulla Co. Targets Underage Alcohol / Tobacco Sales

The Wakulla County Sheriff’s Office conducted a two day undercover operation to combat the sale of alcohol, Spice and tobacco to underage teenagers, according to Sheriff David Harvey.

The most demanded tobacco products are cigarettes as Camel Blue cigarettes or Marlboro Red cigarettes.

Members of the Criminal Investigations Division and WCSO Narcotics Unit began the operation March 22 and visited eight Wakulla County businesses to determine if the businesses were selling products to underage citizens.

A 17-year-old male entered the Chevron gas station located at 2911 Crawfordville Highway and departed after purchasing a four pack of beer, cigars and a packet of Spice. Lt. Sherrell Morrison identified the clerk through the teenager and issued Timmy Jerrell Hills, 30, of Tallahassee a notice to appear in court for selling liquor and tobacco to an underage age person.

On March 23, the same operation issued a notice to appear to Melanie Anne Gestl, 55, of Crawfordville for selling liquor to a person under age 21. The teenager purchased alcohol at the Sky Box bar at 2581 Crawfordville Highway. The teenager was allowed to purchase beer.

On March 23, Mikel Lianne Coleman, 21, of Crawfordville was issued a notice to appear in court for selling alcohol to a person under age 21. The operation targeted Victor’s restaurant at 2000G Crawfordville Highway. The teenager walked into the establishment and purchased a beer.

“Several citizen complaints have been received by my office alleging that underage citizens could purchase alcohol or tobacco products at these locations in Crawfordville,” said Sheriff Harvey. “We will continue to monitor this type of activity to make sure that we are limiting underage access to these products.”

The undercover operation visited five other locations where the underage teenager was refused his request to purchase the products.

Tobacco Corporations Step Up Invasion of Developing Countries

Facing greater restriction in the USA and other industrialized countries, transnational tobacco companies are increasingly marketing their products in developing countries, particularly among women and adolescents.

While smoking rates in some industrialized countries are decreasing at about 1% a year, those in developing countries are increasing at around 3% per year. It is estimated that, if current trends persist for the next 30 years, seven million people from developing countries will die every year from smoking-related diseases.

For the past several years, corporations such as Philip Morris,producer of Virginia Slims cigarettes, RJ Reynolds, creator of Camel cigarettes and British-American Tobacco, producer of Dunhill cigarettes have been expanding rapidly in Eastern Europe, Asia, Africa and Latin America.

Tobacco-provoked deaths can only add to the inequities in health of ethnic and minority populations. Jeanette Noltenius, an expert on tobacco and alcohol abuse issues, stated, “In the US, minorities such as Hispanics have been specifically targeted by the tobacco companies since the early 1960s, and have received a double dose of advertising (in Spanish and English).”

According to data from the Bureau of Census, US Department of Commerce, Latino smoking youth will triple in size in 2020 in the U.S., increasing from 9% of the national youth population to 19%.

Since the early 1980s, US trade officials, with help from the Office of the US Trade Representative (USTR), have led a sustained campaign to open markets in Japan, South Korea, Taiwan and Thailand among the Asian nations.

In Taiwan, US officials' efforts to force Taiwan to open its markets to US tobacco products have resulted in increased smoking, particularly among women and children. Talking about US government support for American tobacco companies, a corporation executive remarked, ‘We expect such support. That's why we vote them in.’

These actions have prompted the Asia-Pacific Association for the Control of Tobacco to protest strongly at what they consider an invasion of their countries by US companies targeting Asian women and children. The Association has complained about the strong-arm tactics used by US government officials in their countries. A report from the US General Accounting Office established that ‘US policy and programs for assisting the export of tobacco and tobacco products work at cross purposes to US health policy initiatives, both domestically and internationally’.

Several studies have shown that in the poorest households in developing countries 10 percent or more of the total household expenditure is on tobacco. As a result, there is less money to spend on some basic items such as food, education and health care needs, thus increasing malnutrition, illiteracy and premature death.

In China, tobacco companies have been moving steadily inland with intense promotional campaigns. It is estimated that of the world's 1.71 billion smokers, more than 350 million are in China, where lung cancer has been increasing at a rate of 4.75% a year.

The Chinese government is facing the dilemma of promoting tobacco cessation policies while it is heavily dependent on earnings from the state-run monopoly tobacco company. However, researchers with the School of Public Health at the University of California state that raising the tobacco tax fifteen cents per cigarette pack could save more than 13 million lives and generate $9.5 billion in revenue for the Chinese government.

Lured by financial gains from growing tobacco, millions of hectares in China are presently under cultivation. Gains from the sale of tobacco, however, may be just short-term, since the costs of treating lung cancer and other related diseases amply exceed the tobacco profits. According to experts, those excess costs are $200 billion annually on a global scale, one-third of which is incurred by developing countries.

While anti-smoking efforts gather momentum in the USA, those efforts are far less effective in developing countries. Such countries' policies will not be as effective unless transnational tobacco firms are made to limit their aggressive advertisements.

Countries in Asia and Latin America are conducting health-education campaigns and have passed legislation to control smoking. Up to now, several countries worldwide have enacted legislation to control tobacco consumption. Although in general this legislation has been passed at the national level, in the USA, Canada, and in several countries in Latin America and the Caribbean these laws are being enacted by state or local bodies.

Despite increasing condemnation by public health officials and the World Health Organization (WHO), international companies continue with their indiscriminate tobacco-promotional efforts in developing countries, at a high human cost. As things stand now, only a multidisciplinary strategy including education, taxation, legislation, and regulation of trade practices of transnational corporations will be able to control this pandemic.

MCCH Bd. reviews tobacco policy

A recommendation by the Murray-Calloway County Hospital administration to allow for the use of tobacco products by hospital patients, visitors and employees has been delegated to a committee for further study by the MCCH Board of Trustees.
The topic originally came up during a meeting of the personnel committee Tuesday afternoon. John Wilson, vice president of human resources, presented the committee a report comparing the hospital’s existing tobacco-free policy to standards set by the Joint Commission, a national hospital accreditation group.
According to Wilson, a portion of MCCH’s policy is not in line with the Joint Commission, something that may turn into a black mark when it comes time for the group to re-evaluate the hospital. The Joint Commission standard reads if a hospital restricts tobacco use but allows exceptions, a designated area must be included in the policy. While MCCH allows an exception for patients to smoke on outdoor hospital grounds, there is no designated area in hospital policy.
Wilson presented two options to the committee to get into compliance. First, he said the hospital could simply modify the existing policy to remove any exceptions. Second, they could designate a smoking area and build a small shelter. There was some discussion over cost, location and how to handle visitors and employees, who would not be permitted to use the shelter. Wilson said visitors especially would be hard to enforce.
Hospital employees are currently allowed to smoke off-campus during non-paid lunch time. Normal breaks are not included because they are considered paid time. However, committee members noted there seems to be little enforcement of the policy, including at the Spring Creek Health Care facility. It was noted how many employees will cross busy streets or stand close to traffic, creating potential hazards.
“I think, as an institution, we have been poor neighbors,” said board chair Dr. Sandra Parks.
Interim CEO Brad Bloemer explained the administration’s formal recommendation included visitors and employees. The location at MCCH would be in the graveled area next to the Emergency Room in the South Tower. At Spring Creek, patients would be allowed to smoke at Station 2 and employees would go to an alternative location yet to be determined.
Dr. Rob Williams, chief of staff and member of the board and personnel committee, questioned the timeline and rush to get something done. Williams said it needed to happen quickly because of the Joint Commission, which will begin review of MCCH at some point in the future. Parks moved to accept the recommendation and send it to the full board for discussion and Dr. Burton Young seconded. Parks, Young and Murray Mayor Bill Wells voted yes, Williams voted no and Calloway County Judge-Executive Larry Elkins abstained.
In Wednesday’s full board meeting, Wilson presented the recommendation for discussion. Elkins asked if the issue had come up because of a policy change by the Joint Commission, but Wilson said it had been that way from the beginning but had never been noticed. Williams questioned the design and cost of the shelter itself, saying his concern was in giving approval to something that hasn’t been properly researched.
“The only current issue is, in the Joint Commission, it hasn’t come up before,” Williams said. “We don’t want to be in a hurry.”
The enforcement of the policy was brought up again, given the high number of employees that can be seen on the street smoking.
“It’s upsetting to me to see our employees sitting on the street smoking. I don’t want them to think we are encouraging smoking but on the other hand it’s a good idea to confine it,” said board vice chair Steve Owens.
When discussion turned to specifics of the shelter itself, some movement was made toward attempting to pass a temporary measure to try and come into compliance quickly and return to the issue at a later date. No motion was made, and board member David Garrison asked if it would be better delegated to a committee for further review. Williams, Young and Hal Kemp volunteered to serve on the committee and the motion passed unanimously by the board. The committee will also include members of the administration team, yet to be determined. Young said they would plan to bring findings to next month’s board meeting.
The hospital posted a strong financial result for January, with nearly $1 million in operational income and a total of $779,000 in net income.
“We continue to do very well,” Bloemer said. “It was the best month in several years. We’ve come a long way in the last two months and are up in just about every area in the hospital.”
Bloemer cited salary expense as having a large impact, which were just over $250,000 below budget. He said the staff has been doing a very good job of monitoring productivity. Another factor in the good month is a high daily census averaging 94. Numerous days have seen the hospital at or near capacity. While January is what Bloemer calls the “heart of the business season,” he said results were still exceptional.
Lisa Ray, vice president of patient care services, told the board they have designated two ER rooms for bed holding when the hospital is at capacity and patients are waiting. She said they can begin treatment while rooms are emptied and cleaned and it has not interfered with ER traffic or caused patient complaints so far.
In other business, the board:
• heard a complimentary report on anesthesiology from Williams, saying the facility is operated smoothly and with more local employees and less that travel in,
• heard an update on the upcoming half marathon from Keith Travis, vice president of physician development. Travis said more than 350 people have registered for the April 16 event and he expects an estimated 350 more,
• heard no recommendations from the Board Office Nominating Committee. Parks said the committee was not prepared to make a nomination but may do so at the next meeting, and
• held an executive session for personnel matters.

31 tobacco distributors fined for price-fixing

The Fair Trade Commission (FTC) slapped fines totaling NT$21.9 million (US$741,995) on 31 tobacco distributors Thursday for conspiring to fix the prices of various tobacco products.The most known tobacco products are cigarettes, they can be of different brands: Vogue cigarettes, Virginia cigarettes or Rich cigarettes.

It marks the first time tobacco dealers in Taiwan have been punished since the FTC was established in 1992.

The results of an investigation by the FTC show that the distributors, affiliated to Japan Tobacco International, held three meetings last May in which they decided to raise the prices of 36 products from June, including Mild Seven cigarettes, the prices of which were increased from NT$660 per carton to NT$680.

Also in the meetings, the distributors agreed to set aside NT$10 to NT$15 from every carton of cigarettes sold and deposit the funds in accounts they held separately in a Taipei City bank, as a form of insurance to make sure they all stuck to the terms of their price-fixing agreement, the FTC said.

The distributors decided that the deposits could only be withdrawn after three months, and accountants were hired to supervise the distributors to make sure they deposited the money regularly into the accounts, the investigation revealed.

According to FTC spokeswoman Shih Hui-fen, the commission began a probe into the case last June after receiving tip-offs from informers.

The distributors were questioned in July as part of the investigation, prompting them to drop the prices of their products over the following months, Shih said. (By Hsieh Jiun-