Unfiltered: Conflicts over Tobacco Policy and Public Health
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《新英格兰医药杂志》
On February 27, the Framework Convention on Tobacco Control came into force, 90 days after ratification by the 40th signatory to this first health treaty negotiated under the auspices of the World Health Organization. The treaty codifies policy approaches to tobacco control, mostly as translated from lessons learned in developed countries such as the United States, Canada, and the United Kingdom, where the prevalence of smoking among men declined by more than 50 percent between the mid-1960s and 2001. In this collection of eight national analyses and a perspective on the European Union, a timely story is told from different cultural and political points of view, including those of liberal democracies, where respect for the rights of individual persons must be balanced against collective efforts to support the public good through political action.
Each chapter in this thoroughly referenced book delves into history, sometimes as far back as 500 years, to gain insights into which policies might be responsible for progress in the countries discussed. Furthermore, the book tries to explain why so many idiosyncrasies exist in the complex world of tobacco control. In most cases, the power of information as presented in reports from the Royal College of Physicians and the U.S. Office of the Surgeon General helped drive political action, research, and public opinion to change the view of smoking as a normal activity. Nevertheless, variability in the acceptance of this information created systems of official denial (as evidenced by a lack of enforcement of various laws regarding advertising and smoking in public places) in France, Germany, and Japan. Historically, authoritarian approaches to tobacco control in some cases created a deeply rooted resistance to the paternalistic nature of public health efforts on tobacco control. Germany may have subconsciously justified its resistance to such efforts in the European Union because of sensitivity to its authoritarian history.
A chapter on the history of tobacco control in the European Union presents a lucid explanation of how multinational health policies (such as a ban on cigarette advertising) were trumped by concern for tobacco agriculture in some countries in the European Union. Information from previously secret tobacco-industry documents helps us to dissect the complexities of tobacco-control policies in a political structure that was established not for health advocacy but for support of trade and economic cooperation. Tobacco, to many of the European Union member states, is simply an agricultural commodity and not a health issue. Now, however, the Framework Convention on Tobacco Control provides a broader perspective on international cooperation with respect to tobacco control, including a more focused concern about the health care costs of tobacco use, the adverse effects of cross-border smuggling, and the need to harmonize tobacco taxes for reasons of both health and revenue. One only hopes that the fatuous economic arguments described in this book about the "benefits" of premature mortality attributable to smoking — that it reduces expenditures on social services — will die the quick death they deserve.
A chapter by the esteemed historian and ethicist Allan M. Brandt is provided as cultural background to the mix of national analyses. He adds a fascinating review of how cigarette smoking devolved from a social necessity in the 1950s (as described by the doyen of civility, Emily Post) to pariah behavior necessitated by nicotine addiction in the 1990s. Brandt asserts that a "tipping point" has been reached in the change in attitudes toward tobacco use, so that progress is now made not as a result of some magic-bullet policy but, rather, as the result of a cultural shift and a change in the perception of risk versus pleasure.
What we are left with in this capable if sometimes dense review of history and policy is a guarded understanding of how evidence, culture, and politics have converged to change the acceptability of tobacco use. A social gradient has emerged in tobacco-control policy: the developed world continues to implement policies that reduce the adverse outcomes of tobacco use while the poor nations of the world continue to accept the financial and cultural "benefits" of the evil weed. As the Framework Convention on Tobacco Control comes into force, further historical precedents may be set as this truly multinational process is implemented and the public health lessons of the countries described in this book are learned elsewhere around the world. However, it is ironic that the country in which many of these lessons have been learned probably will not ratify the treaty. The United States may now find itself a bystander to the global public health history being made with the Framework Convention on Tobacco Control.
Thomas E. Novotny, M.D., M.P.H.
University of California, San Francisco
San Francisco, CA 94105(Eric A. Feldman and Ronal)
Each chapter in this thoroughly referenced book delves into history, sometimes as far back as 500 years, to gain insights into which policies might be responsible for progress in the countries discussed. Furthermore, the book tries to explain why so many idiosyncrasies exist in the complex world of tobacco control. In most cases, the power of information as presented in reports from the Royal College of Physicians and the U.S. Office of the Surgeon General helped drive political action, research, and public opinion to change the view of smoking as a normal activity. Nevertheless, variability in the acceptance of this information created systems of official denial (as evidenced by a lack of enforcement of various laws regarding advertising and smoking in public places) in France, Germany, and Japan. Historically, authoritarian approaches to tobacco control in some cases created a deeply rooted resistance to the paternalistic nature of public health efforts on tobacco control. Germany may have subconsciously justified its resistance to such efforts in the European Union because of sensitivity to its authoritarian history.
A chapter on the history of tobacco control in the European Union presents a lucid explanation of how multinational health policies (such as a ban on cigarette advertising) were trumped by concern for tobacco agriculture in some countries in the European Union. Information from previously secret tobacco-industry documents helps us to dissect the complexities of tobacco-control policies in a political structure that was established not for health advocacy but for support of trade and economic cooperation. Tobacco, to many of the European Union member states, is simply an agricultural commodity and not a health issue. Now, however, the Framework Convention on Tobacco Control provides a broader perspective on international cooperation with respect to tobacco control, including a more focused concern about the health care costs of tobacco use, the adverse effects of cross-border smuggling, and the need to harmonize tobacco taxes for reasons of both health and revenue. One only hopes that the fatuous economic arguments described in this book about the "benefits" of premature mortality attributable to smoking — that it reduces expenditures on social services — will die the quick death they deserve.
A chapter by the esteemed historian and ethicist Allan M. Brandt is provided as cultural background to the mix of national analyses. He adds a fascinating review of how cigarette smoking devolved from a social necessity in the 1950s (as described by the doyen of civility, Emily Post) to pariah behavior necessitated by nicotine addiction in the 1990s. Brandt asserts that a "tipping point" has been reached in the change in attitudes toward tobacco use, so that progress is now made not as a result of some magic-bullet policy but, rather, as the result of a cultural shift and a change in the perception of risk versus pleasure.
What we are left with in this capable if sometimes dense review of history and policy is a guarded understanding of how evidence, culture, and politics have converged to change the acceptability of tobacco use. A social gradient has emerged in tobacco-control policy: the developed world continues to implement policies that reduce the adverse outcomes of tobacco use while the poor nations of the world continue to accept the financial and cultural "benefits" of the evil weed. As the Framework Convention on Tobacco Control comes into force, further historical precedents may be set as this truly multinational process is implemented and the public health lessons of the countries described in this book are learned elsewhere around the world. However, it is ironic that the country in which many of these lessons have been learned probably will not ratify the treaty. The United States may now find itself a bystander to the global public health history being made with the Framework Convention on Tobacco Control.
Thomas E. Novotny, M.D., M.P.H.
University of California, San Francisco
San Francisco, CA 94105(Eric A. Feldman and Ronal)