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Should smoking in outside public spaces be banned? No

Authors:

Abstract

After success in stopping smoking in public buildings, campaigns are turning outdoors. George Thomson and colleagues (doi:10.1136/bmj.a2806) argue that a ban will help to stop children becoming smokers but Simon Chapman believes that it infringes personal freedom
HEAD TO HEAD
76 BMJ | 10 JANUARY 2009 | VOLUME 338
Should smoking in outside public
spaces be banned?
cies. California has banned smoking within
25 feet (7.6 metres) of outdoor playgrounds.
United Kingdom, Australian, and New Zea-
land authorities have been explicit about
the need to reduce the modelling of smok-
ing to children as a justification for this type
of outdoor smoking restrictions.9-12 Policies
encouraging or requiring
other outdoor smoke-
free areas have been
introduced in the past 10
years in North America,
Australasia, Hong Kong,
Singapore, and elsewhere.
13
Reducing the
modelling of smoking to children has often
been given as a justification for introducing
these restrictions.
Are outdoor smoke-free policies practical?
How best to reduce the visibility of smok-
ing? Media campaigns can promote not
smoking in the presence of children as a
social norm.
14
Legislation and other uses
of law can expand smoke-free policies to
ensure the inclusion of all public areas
where children predominate. These areas
include schools, parks and playgrounds,
swimming pool complexes, sports grounds,
and parts of beaches. The success of out-
door bans depends on the size of the areas
covered, the ways the policy is communi-
cated (for example, signage), and the extent
of public support.15
Reports from Britain, New Zealand, and
parts of Australia and the United States
indicate majority support for restricting or
banning smoking in outdoor areas where
there are children.
15-20
We are aware of no
evidence that outdoor smoke-free policies
have resulted in a public backlash against
other advances in tobacco control.
Ethical and international treaty
considerations
Children are a highly vulnerable population,
susceptible to the influences of adult behav-
iours. Protection from addiction can be con-
sidered to enhance overall freedom, given
that most smokers regret ever starting.21
We may not yet be certain that outdoor
smoke-free areas reduce smoking uptake;
the necessary studies have not been carried
out. However, where there is uncertainty in
policy making, any assessment of the balance
of benefit and harm should put the protec-
tion of children first.
22
This is because of the
extent and severity of the hazard that taking
up smoking poses to children and the theo-
retical and empirical evidence for a role mod-
elling effect on smoking uptake. The principle
of giving primacy to the
protection of children is
also underpinned by inter-
national treaty obligations.
The United Nations Con-
vention on the Rights of
the Child requires that in making policy,
children’s rights must be put first, and govern-
ments “shall undertake all appropriate legisla-
tive, administrative, and other measures for
the implementation of the rights.”23
Adverse effects from outdoor smoke-free
areas are largely restricted to the possible loss
of amenities for some smokers.
We argue that society has an ethical duty
to minimise the risk of children becoming
nicotine dependent smokers. A reasonable
step is banning smoking in selected outdoor
areas frequented by children. Children need
smoke-free outdoor places now, to help nor-
malise a smoke-free society.
Competing interests: All authors have done contract work
for health non-governmental organisations, the New Zealand
Ministry of Health, or WHO on tobacco control research.
Cite this as: BMJ 2008;337:a2806
Legislation to ban smoking
indoors in public places is
now commonplace, driven
mainly by the need to protect non-smokers
from exposure to secondhand smoke. A
new domain for tobacco control policy is
outdoor settings, where secondhand smoke
is usually less of a problem. However, the
ethical justification for outdoor smoking
bans is compelling and is supported by
international law. The central argument is
that outdoor bans will reduce smoking being
modelled to children as normal behaviour
and thus cut the uptake of smoking. Out-
door smoke-free policies may in some cir-
cumstances (such as crowded locations like
sports stadiums) reduce the health effects
of secondhand smoke
1
; will reduce fires
and litter
2
; and are likely to help smokers’
attempts at quitting.
Need to reduce modelling
There is no simple answer to the question of
what causes children to take up smoking.
3 4
We know, however, that children tend to copy
what they observe and are influenced by the
normality and extent of smoking around
them.
5-7
Many smokers recognise that their
smoking affects children’s behaviour.8
The primary strategy for tobacco con-
trol is reducing the prevalence of smoking,
and such reduction will in itself mean that
smoking is less visible in society. But the
modelling of smoking can also be reduced
by policies to restrict smoking in the pres-
ence of children. The entrenched nature of
tobacco use in most societies, and its highly
addictive qualities, require that such policies
are far reaching. Smoking bans in many out-
door public areas are therefore an important
additional approach to tobacco control.
The need for outdoor smoking restric-
tions is increasingly recognised. Finland,
five Canadian provinces, two US states, and
New Zealand use law to require smoke-free
school grounds. Other jurisdictions (such as
Australian states) use administrative poli-
“Children tend to copy
what they observe and are
influenced by the normality of
smoking around them”
George Thomson senior research fellow, Nick Wilson senior
lecturer, Richard Edwards associate professor, University of
Otago, Wellington, Box 7343, Wellington, New Zealand
george.thomson@otago.ac.nz
Alistair Woodward professor, University of Auckland, Private Bag
92019, Auckland, New Zealand
HEAD TO HEAD
BMJ | 10 JANUARY 2009 | VOLUME 338 77
All references are in the version on bmj.com
Indoor smoking bans draw their
ethical authority from extensive
research showing harm from
prolonged and repeated exposures in homes
and workplaces, over many years. By contrast,
recent agitation to extend bans to outdoor set-
tings like parks, car parks, beaches, and streets
is supported by flimsy evidence. Brief expo-
sures to others’ smoke can produce measur-
able physiological changes.1 2 However, acute
exposure studies typically define brief as 15
to 30 minutes—considerably more than usual
smoky encounters outdoors.3
A recent paper concluded that outdoor
smoke is rapidly attenuated but for those within
half a metre of multiple smokers “between 8
and 20 cigarettes smoked sequentially could
cause an incremental 24-hour particle exposure
greater than . . . the 24-hour EPA [US Environ-
mental Protection Agency] health-based stand-
ard for fine particles.”
4
The authors referred
to bar patios as where this might happen but
state that “sitting next to a smoker on a park
bench” might produce such exposure, despite
also stating that multiple smokers are required
to get to levels that challenge the EPA stand-
ard. “Multiple smokers” are rarely seated on
park benches next to non-smokers for the time
it would take to smoke 8-20 cigarettes.
the toxiogenic hypothesis (that intolerance
of low levels of any environmental agent
explains symptoms either through toxicody-
namic pathways or by sensitising neural path-
ways) and the psychogenic hypothesis (that
idiopathic environmental intolerance is a cul-
turally learnt phenomenon characterised by
an overvalued idea of toxic harm explained
by psychological or psychosocial processes).8 9
The reviews concluded that none of the Brad-
ford-Hill criteria for causation
10
were satisfied
by the toxiogenic theory, but that all of the
criteria were met for the psychogenic theory.
Governments often regulate citizens’ con-
duct to reduce nuisance, regardless of whether
it affects health. Public health research is
debased when it lends bogus credibility to
what are essentially matters of community
preference. If authorities wish to stop smoking
on beaches to reduce litter, they should frame
their actions in terms of litter reduction, not
public health. Landlords wanting to prevent
smokers from renting apartments because
of complaints about smoke drift from other
residents, should be at lib-
erty to do so, but need not
invoke public health justi-
fications.
In most of the world
smoking remains a normal, unremarkable,
and unregulated activity. Health workers in
those nations are desperate to convince gov-
ernments of how reasonable it should be to
remove involuntary tobacco smoke expo-
sure in occupational and indoor public set-
tings. They marshal evidence about disease
caused by long term exposure and staunchly
defend the credibility of that evidence from
the predations of the tobacco and hospital-
ity industries, intent on exposing those risks
as trivial. Opponents of clean indoor air will
point to campaigns against outdoor smoking
and argue that advocates actually want to ban
smoking everywhere. Such views are likely to
undermine the credibility of advocacy for evi-
dence based smoke-free policies to the great
detriment of hundreds of millions of citizens.
This article is adapted from Chapman S. Going too far?
Exploring the limits of smoking regulations.
William Mitchell
Law Review
2008;34:1605-20.
Competing interests: None declared.
Cite this as: BMJ 2008;337:a2804
After success in stopping smoking in public buildings, campaigns are turning outdoors.
George Thomson and colleagues argue that a ban will help to stop children becoming smokers
but Simon Chapman believes that it infringes personal freedom
Paternalism
Some are affronted by the mere sight of smok-
ing. Others have an evangelical mission to use
paternalistic “tough love” to help others quit.
Prohibitions on personal behaviours can be
justified by the right to interfere with the lib-
erty of people to harm to others. But paternal-
ism is most odious when used as a justification
for limiting the choices that adults make when
they put only themselves at risk.
5
Health facili-
ties banning smoking outdoors often justify
this as normative role modelling. This is ethi-
cally unproblematic for staff who are contrac-
tually obligated to observe employers’ policies
but represents ethically muddled thinking
when it comes to patients and visitors, who
are not somehow “owned and controlled” by
health authorities. If they harm no one else by
smoking outdoors, they ought not be coerced
into signing up to the health promotion values
of a hospital when visiting.
Many smokers support paternalistic policies
designed to discourage their smoking. But we
do not evaluate the ethics of public health by
the willingness of people
to give up their autonomy,
nor with the success of
commandments to obey
laws. The ethics here is
about respect for the autonomy of individu-
als to act freely, providing their actions do not
harm others.
There are few differences between the
chemistry of tobacco smoke and that gener-
ated by incomplete combustion of any bio-
mass: leaves, campfires, petrol, or barbecued
meat.
6
7
Secondhand smoke is not so uniquely
noxious that it justifies extraordinary controls
of such stringency that zero tolerance outdoors
is the only acceptable policy. Park barbecues
aren’t banned for the obvious reason that the
amount of smoke involved is trivial. Zero tol-
erance of tobacco smoke in outdoor public
settings is nakedly paternalistic.
Problems of health argument
Advocates for smoke-free outdoor areas
include those who passionately attest to being
severely affected by even the tiniest exposure
to smoke. If public health policy is to be evi-
dence based, such claims need to be subjected
to scientific assessment.
Two reviews examined evidence for both
“Zero tolerance of tobacco smoke
in outdoor public settings is
nakedly paternalistic”
Simon Chapman profe sso r of pub lic hea lth ,
Un iver sit y of Sydn ey, S ydn ey, A ust ral ia
sc@med.usyd.edu.au
These two articles were posted on bmj.com
on 11 December 2008. In the accompanying
online poll, 416 readers (57.66%) voted yes
and 307 (42.34%) voted no.
WHERE DO YOU STAND ON THE ISSUE?
Tell us on bmj.com
PHOTOFUSION PICTURE LIBRARY/ALAMY
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Book
71 selected essays on public health published between 1982-2016 in journals, newspaper opinion pages and blogs by Simon Chapman, professor of public health at the University of Sydney Full text (pdf) available here https://open.sydneyuniversitypress.com.au/9781921364594.html
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