CHW: Can you tell me your perspective on the similarities and differences in the tobacco control effort in Australia and the United States, and what’s special about how these conflicts have played out here in Australia?
Chapman: What is similar is that both Australia and the United States are very robust democracies where freedom of expression, criticism of the government, criticism of the corporate sector … all of those issues are not problematic. Whereas in places like China or Vietnam, talking about advocacy is like talking Esperanto because the notion that you could ever make an argument against government or even against corporations is pretty much unheard of. So that is the major similarity.
In Australia, in tobacco control, we have not had the problem that you’ve got in the States with the First Amendment and the issue of free speech being taken to include commercial free speech. Very early on in Australia, arguments were put forward about banning tobacco advertising and promotion, and there was never any serious impediment to that which was constitutionally based or, indeed, based in values that would suggest that corporations could somehow not be silenced in their exercise of free speech. The tobacco industry, of course, fought very hard against any restrictions, along the lines of trying to play games about getting us to reach an impossible level of evidence about cause and effect of advertising and smoking. But those arguments petered out and in the early 1990s we got rid of all tobacco advertisements in Australia. Today you can’t see any advertising anywhere except for very limited point of sale promotion inside tobacconists.
CHW: Are there other cultural or political differences that influence attitudes towards tobacco?
Chapman: Another difference between the States and Australia in terms of tobacco control is concern about what I would characterize as very trivial erosions of personal freedom like having to wear seat belts or a motorcycle crash helmet. Here in Australia, there has not been any significant civil libertarian resistance, whereas I’m very aware that in those two areas there has been conflict in the States. But we haven’t had anything like that, so arguments in Australia about, for example, rules about designating places where we couldn’t smoke were pretty well accepted by the population. The idea that it was fair and just that the government should intervene with laws when somebody was harming your health through second hand smoke was reasonable. So the problem always became the vested interest groups, mainly the tobacco industry, but more importantly, third parties acting on their behalf. This included principally the hospitality industry and the hotel industry, and what we call “clubs”, places where members can gamble, smoke and drink. Australia has successfully imposed restrictions on smoking in these places.
CHW: I know you have also worked on the issue of reducing gun violence in Australia. How does your experience here compare to the US?
Chapman: Well, again, we have nothing like the Second Amendment, or a right to bear arms. In 1996, we had a horrendous civilian massacre in Port Arthur, a historic tourist site in Tasmania, where a man ran amok with military style semi-automatic weapons and killed 35 people.
That was a tipping point for a lot of gun control advocacy that erupted in the decade leading up to that. I describe these experiences in my 1998 book Over our dead bodies: Port Arthur and Australia’s fight for gun control. ((Read the British Medical Journal review) In that book, I make the case that in health care we have disaster plans where every working hospital is prepared for a major industrial explosion or an aircraft crash or something like that. In public health we also ought to have disaster plans because sometimes big public health incidents, like a gun massacre, can trigger (sorry about the bad pun) major reconsiderations in public health law, and that was certainly what happened after Port Arthur.
CHW: By disaster plans, you mean a plan to move advocacy forward if there’s a window for policy change?
Chapman: That’s right. It opens a window of opportunity where a major disaster can suddenly concentrate decades of advocacy. All of a sudden, communities start using the arguments that you’ve been seeding for years and years, leading to a huge avalanche of public outrage that something should be done now. After the Port Arthur massacre, we found terms and phrases that we’d been using for years suddenly being repeated by politicians, police officers, and citizens in ways that showed the groundwork for advocacy comes home to roost when public concern is fired up by these incidents.
CHW: Have these same dynamics played out in tobacco control?
Chapman: With tobacco, the major challenge is that if you don’t do something about control today and you postpone it for weeks, months, or even years, there is not the obvious temporal association between something not having been done and the disease incidence down the road. It’s the old difference between statistical victims and what’s been referred to as the rule of rescue, where you’ve got identifiable, named individuals with acute health problems, saying the government should be providing this new cancer drug for me or reducing waiting lists in public hospitals. Whereas, with chronic disease, of which tobacco control is a great example, you can run the same arguments about harm reduction or controlling the tobacco industry for years and years. It’s really only when windows of opportunity open – and they include things like political charismatic leadership coming along where you start getting the substantive kind of gains. I’ve never seen really tobacco control events without a strong political advocate who comes along and decides to do something about it.
CHW: That’s an interesting observation. So you’re suggesting acute crises like gun massacres or a toxic release open their own windows of opportunity for policy change whereas chronic health problems related to tobacco, alcohol or food may depend more on charismatic leadership. Can we return for a moment to gun control? In the United States, as you know, one of the key obstacles to reducing gun violence is the National Rifle Association. Its well-funded and skilled lobbying operation has been remarkably successful in blocking public health measures, even when public support for such measures is strong. What’s the situation here in Australia?
Chapman: Well, gun ownership is pretty widespread in Australia but it’s not as common as in the U.S. Here, however, the organized gun lobby is fairly small. Since the Port Arthur massacre, people who want to have a gun are obliged to be a member of a sporting shooting club or show a history of hunting. The equivalent of the NRA in Australia is called the SSAA, Sporting Shooters Association of Australia. SSAA has become very well off because all shooters now have to undertake an approved safety instruction course, as if safety was the issue. Safety is really a trivial component of gun injuries and deaths. To own a gun here, individuals have to register their attendance at a shooting range a minimum of four times a year. And the criterion of ownership of a gun for self- defense was explicitly removed. You can’t just say, “I want a gun for self defense.” The only reasons you can have a gun are if you are a member of a sporting shooting club or you are a bona fide gun collector, and then you’ve got to show evidence you’ve been collecting for a long time. It’s very difficult to become a new collector. The third reason to have a gun is that you have explicit permission from a rural property owner to go on their property and shoot kangaroos and feral pigs, or whatever. But just the idea that you can have a gun if you want to is not allowed.
CHW: So the SSAA has developed a close interdependent relationship with the government?
Chapman: Yes, they get training course fees and club registration fees and so they become quite powerful. For example, we had a state election last week and I discovered that the SSAA had given $350,000 to a political party called the Shooters Party to try and get them elected. In Australia, that is a big political donation. So the question is where did they get the money? They get it from shooter’s licenses so the irony is that the government will be opposed by a funding stream its own laws created.
CHW: How did you become involved in public health advocacy? Do you think there’s a potential for bringing health advocates together across issues like tobacco, guns, alcohol and so on?
Chapman: I got into advocacy because I had a typical community health education job when I was a younger guy, and a few like-minded colleagues and I became frustrated with being obliged to work in downstream problem solution, educating school teachers, that sort of thing. We could see all of this corporate malfeasance and industry promotion of unhealthy behavior all around us. I was working in the drug and alcohol areas, so I thought, if we’re going to be serious about reducing drug and alcohol problems, we need to address the upstream stuff. So I got involved in forming a public interest group that was a typical, totally unfunded, flying by the seat-of-the-pants opportunistic pebble in the shoe of the tobacco companies. In the early 1980s, we had a major victory when we were able to engineer an end to the involvement in a leading cigarette advertising campaign of Paul Hogan, the actor, who was Crocodile Dundee. Hogan was on every advertisement for this particular brand, and he had major appeal to children. The tobacco industry had a self- regulatory rule that just didn’t work so we challenged that process and won. All of a sudden with no resources we made a difference by strategically using the media and creative research strategies. So I started getting interested in advocacy principally in tobacco control. Then in the early 1990s, I got involved in gun control.
CHW: So you have had a lot of experience on several different campaigns. As someone who is interested in the advocacy process, how do you decide which issues to work on, which to study?
Chapman: Well, you can’t do everything in advocacy, so I do the things I am interested in and feel are important and I try to do things that when windows of opportunity open I can jump in and do something. Being opportunistic is so vital for effective advocacy and if you can’t make room for those opportunities when they open you’re not going to be very effective.
CHW: Are you talking mainly about media advocacy here?
Chapman: Media advocacy is, of course, only one component of the overall public health advocacy enterprise, but to me it’s rare for an advocacy campaign to succeed if there is no media advocacy component. It’s usually the elephant in the living room that runs it.
CHW: You’ve written about the public discussion of tobacco. How do you think media advocacy has affected that dialogue?
Chapman: The tobacco industry in Australia has largely vanished from public discourse. In fact, I’ve got a graduate student of mine working on going back and looking when it was that the tobacco industry started disappearing from the press. It’s around about the late l990s when all those documents came out because, of course, it was then so easy just to contradict everything they said by showing them their own words. But they now operate almost entirely through elite-to-elite communication channels, you know through funding of political parties, through funding of free enterprise foundations, that sort of thing.
CHW: So in effect, you’re arguing that successful media advocacy by tobacco control activists re-framed the media discussion and drove the industry to find new channels of communication. How do you think this lesson applies to other industries, say alcohol or food?
Chapman: The alcohol industry is the one where I get the most requests from people who say, “Can you do for alcohol what you helped do for tobacco?” To me, there are enormous fundamental differences between the two. The main one is that there is no safe level of tobacco use, whereas there is a lot of very respectable epidemiology that suggests that low to moderate alcohol use is actually beneficial. So in alcohol there are not too many points of comparison with the core messages of tobacco control which are: “Get rid of all advertising and promotion”, “Put the price of tobacco products up significantly”, “Reduce opportunities to get hold of tobacco”, and “Limit sales outlets”. I haven’t heard a really compelling call for banning all alcohol advertising.
On the other hand, my alcohol advocacy colleagues tell me about issues that do call for advocacy. For example, you can buy bulk wine in Australia in these boxes with taps on the bottom. You can get four liters of this wine for under ten bucks, and it’s the favored drink of indigenous people who have extraordinary health problems from alcohol. It’s taxed at a much lower rate than table wine, quality wine. But there’s no rationale for different levels of taxes. There ought to be a standard way of taxing all beverages by alcohol content.
CHW: I’d like to switch gears here and talk about teaching about the impact of corporate practices on health and the role of public health advocacy. How do you approach this subject in your public health curriculum?
Chapman: The very first lecture I give in my Public Health Advocacy course is a description of the traditional host, environment, agent and vector model from infectious disease epidemiology. And I say, let’s apply this to chronic disease epidemiology and to the tobacco industry, tobacco control. What is the vector? The vector is the tobacco industry. I tell my students that any comprehensive approach to chronic disease control, injury prevention, whatever, if you don’t address the vectors who are profiting from the proliferation of abusive behaviors, or dangerous products, then you’re going to miss the boat. So vector control in chronic disease invariably takes you into consideration of industry groups who are out to profit.
CHW: And do you see this as a model for public health folks or do you think it has a potential for mobilizing more popular political support?
Chapman: I see it as both. When politicians favor downstream solutions, more education, more information, rather than upstream solutions, that’s because the comprehensive control model that they’re using does not embrace vector control, control of industry. At the same time, I also think that sometimes industry can be very much a part of the solution.
The food industry is a particularly complex area for public health advocacy. If I ask nutritionists and dieticians, “Exactly what is it that you want people to put in their mouths?” they give me laundry lists of a good diet. And if I ask, “And where do you get hold of that diet?” they say, “Oh, you can buy it at shops.” And I say, “Well, who puts it in shops?” The food industry puts it in shops.
Any view of the future of nutritional change which sees the food industry as being only part of the problem, rather than part of the solution, is myopic. They are certainly part of the problem, but I think that public health advocates also need to understand how coalitions and relationships and networks can be formed with the food industry to push it in the right direction.
Too often the public sector and the NGO sector people concerned about obesity just talk to each other. But where does the average person get nutrition information? They get it from food labeling and from advertising. They may get a bit from public sector, but the total budget of the average bread company is bigger than the government’s entire nutrition campaign budget. So sometimes the role of government can be to stimulate the market to do something differently. With the tobacco industry, people say it’s so easy, so black and white.
CHW: What do you see as the global dimensions of health advocacy to change corporate practices?
Chapman: Well, in tobacco, there has been an immense amount of global networking and information and strategy exchange going on. For example, 190 NGOs have been very instrumental in making sure that the Framework Convention of Tobacco Control just passed in 2003 is fully implemented.
And the Internet has absolutely revolutionized advocacy practice. Not a day goes by where somebody isn’t saying, “Do you know this organization?” “Do you know that individual?” “This has happened. What would you do?” “Is this guy an industry stooge?” So that has been immensely important. I’m not as well connected with gun control any longer, but a colleague of mine runs the major website for the world, gunpolicy.org , which reports on breaking news about guns and gun control from around the world.
CHW: So if I can come back to ask your opinion on the underlying question. What do you see as the potential for campaigns, advocacy networks or actual social movements that would bring greater attention and action on some of these issues, particularly in Australia?
Chapman: I think there’s a lot of potential. Public health has got many specializations within it. You walk around the corridors of this building, the public health building at the University of Sydney, there are statisticians, behavioral scientists, epidemiologists, and anthropologists, and you walk into major NGOs and there is a Director of Marketing, of Community Development, of Campaigns, but there is seldom an Advocacy Director. Advocacy is unfortunately something that people seem to do in their spare time almost. In University settings, there are not a lot of people around the world who are teaching courses on Public Health Advocacy in Masters of Public Health degree programs.
Now in the States I know you’ve got that Hatch Law that prevents government workers from engaging in certain kinds of political activities. . There’s not the problem with that here. Here in Australia, advocacy isn’t a dirty word nearly as much as it is in the States. Government officials, of course, can’t advocate but NGOs are expected to do that. Academic research in the advocacy process is an emerging specialization within public health. The course I teach here is problem based. I give students realistic scenarios and I say let’s analyze what’s going on here, and I ask a series of structured questions. What is the public health problem arising from this scenario? What are our public health objectives? What are our media advocacy objectives that would suit our public health objectives?
Is there opportunity that would short circuit the need for advocacy? How are our position and our opponent’s position being framed in public discourse? How is the debate running in the media? Is it about unnecessary debt or is it about commercial freedom? Then drilling down even further, say a reporter phones, you’ve got a chance to say something that’s going to heard by 20 million people, and you’ve got seven seconds to say it. What are you going to say? So actually bringing that analytical process to considering what your intervention is going to be in that seven seconds. And then, are there other strategies in which you would engage beyond the media advocacy? Are there influential people you can see? Can you discredit your opponents?
CHW: Tell me about your new book, Public Health Advocacy and Tobacco: Making Smoking History. Ken Warner, the Dean of the University of Michigan School of Public Health and a long-time tobacco researcher wrote about your book, “ I was fascinated, educated, and occasionally entertained by this broad and deep “manual” of how to do tobacco control in the 21st century.” What’s the aim of your book?
Chapman: Well, I think the goal of tobacco control is to make smoking history. In the book, I describe effective and ineffective approaches, condemn overly enthusiastic policies that ignore important ethical principles, and offer readers a cookbook of strategies and tactics for denormalising smoking and the industry that promotes it. I hope readers will find it useful.
CHW: Thanks very much.