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Edited by Eric A Feldman, Ronald Bayer. Harvard University Press, 2004, pp 394. ISBN 0-674-01334-4
Tobacco policy and public health
With the cover befitting a crime thriller, Unfiltered delivers an honest, unfiltered discussion of contemporary policy debates in tobacco control. The book documents experiences from eight developed countries. These eight include tobacco control leaders Canada, Australia and USA, a mixed bag of European experiences (Denmark, France, and UK), and for contrast, Japan and Germany.
The editors offer several justifications for choosing these economically advanced democracies in that they share a broad commitment to liberal political values and demonstrate an interesting range of beliefs and practices with respect to privacy, autonomy, and paternalism. But there are examples of developing countries with liberal political values and autonomy such as India, the world’s largest democracy, South Africa, and the Philippines which go unmentioned. This is a pity because the issues discussed are as relevant to low income countries as they are to developed nations.
The contributors unravel their countries’ arduous journeys into tobacco control. A meticulous discussion is provided on how they confronted three key policy issues: advertising controls; restricting public smoking; and tobacco tax.
The tension between individual rights and public good is plain. Each country found its own way of framing tobacco control to gain public and political support. The USA’s approach centred on the protection of children, innocent bystanders, and the public purse, a stance that steered clear of paternalism.
Similarly in Canada the prevention of smoking by children formed the basis for legislation as early as 1908 and was reflected again in the 1997 Tobacco Act. Canada’s experience shows substance control in liberal states is undeniably a complex phenomenon. However, there was general consensus that extensive government regulation of tobacco was justified on public health grounds. This contrasts with the Japanese experience, which has similar protection for children, but the government retains its hands off posture toward individual behavioural choice while exercising its paternalistic public health powers in other areas.
Unfiltered’s cross-country cultural configuration of risk provides a fascinating discussion, contrasting the USA with European nations. In the USA, the risks of sidestream smoke shaped a radical reconfiguration of tobacco policy. In other countries these risks are measured against the perceived benefits of smoking, the role of the state as an appropriate protector of public health, and concerns about state intrusions on individual behaviour. Many Europeans found the USA. policy “extremist” or, as the French put it, “too American”. Hence in Europe, where 35% of the population smokes, countries have generally been slower to pass public smoking laws.
Unfiltered’s account of “smoke-free skies” explains the successful internationalisation of regulations instituted by the corporate sector rather than governmental policy. Starting with United Airlines, the first carrier to segregate seating for smokers and non-smokers in 1971, it documents the widespread diffusion of airline bans on smoking, as the cross-national influence of anti-tobacco sentiment and advocacy took effect.
Two recent valuable tools for tobacco control have been the internal industry documents and the Framework Convention on Tobacco Control (FCTC). Using internal documents, a chapter on tobacco control policy in the European region provides a gripping account on how the industry subverted European tobacco control policy. This is an insightful account of how a public health treaty plays out in the context of trade.
Canada, which everyone quotes for its achievement, armed with its own authoritative evidence went through the experience of having industry self regulation defeat legislation. The authors conclude resistance to tobacco control has been most striking in Germany and Japan where almost universally accepted scientific facts on smoking continue to be disputed.
Unfiltered concludes that appropriate policy alone is rarely sufficient to bring about fundamental change in the social patterns that facilitate starting, continuing, or ceasing to smoke. Tobacco control advocates will be confronted with thought provoking questions on the relation between national policies and individual preferences, between legal regimens and social realities. All eight counties show declines in smoking prevalence. Nations that have most vigorous tobacco control policies have witnessed steep declines in smoking rates, but so have countries with weaker anti-smoking strategies.
A vivid analogy is offered: “like surfers, legislators and corporate officials who wish to change everyday social norms must wait for signs of a rising wave of cultural support, catching it at just the right time.” Perhaps the FCTC is that global surfer’s wave.
Verdict: a must read for public health advocates, researchers, and policymakers