Category Archives: Tobacco

New Reports on Food, Alcohol and Tobacco Marketing

In the last few months, government and advocacy organizations have released new reports on the impact of tobacco marketing, inequities in how grocery chains serve low-income neighborhoods, and the alcohol industry’s compliance with its own voluntary guidelines. To help readers keep up, we summarize some of this summer’s publications and provide links to the full reports.

 

As elected officials, public health researchers and advocates increasingly recognize that corporate policies and practices have a major influence on health, Corporations and Health Watch readers may have trouble keeping up with the many reports on the subject. Since these reports often appear in the “gray literature” and are not centrally indexed, it’s easy to miss information that could inform research or practice.  To assist readers in this task, CHW summarizes a few recent reports; we do not review their claims or assess their methodologies.

Bloomberg M. Press Release: Mayor Bloomberg and Shaquille O’neal Announce New Food Standards For City Agencies, September 19, 2008.

On September 19th, New York City Mayor Michael R. Bloomberg and NBA basketball player Shaquille O’Neal announced the launch of New York City’s new food standards designed to improve the nutritional quality of the 225 million snacks and meals served by City agencies each year. These standards make New York City the first major US city to establish nutrition standards for all food purchased or served by city agencies. The new standards cover snacks and meals served in places such as schools, senior centers, homeless shelters, child care centers, after school programs, correctional facilities, public hospitals and parks. The standards mandate City agencies to serve only healthier beverages such as skim or 1 percent milk (with exceptions for babies), phase out deep frying, include two servings of fruits and vegetables in every lunch and dinner, lower salt content and increase the amount of fiber in meals.

Blue Ribbon Commission on L.A.’s Grocery Industry and Community Health.  Feeding our Communities.  A Call for Standards for Food Access and Job Quality in Los Angeles Grocery Industry. Los Angeles, July 2008.  Available in [pdf]

The Alliance for Healthy and responsible Grocery Stores, a city-wide Los Angeles coalition of 25 community, faith-based, labor, and environmental organizations last July released “Feeding Our Communities: A Call for Standards for Food Access and Job Quality in Los Angeles’ Grocery Industry”. Based on public hearings in which residents, industry experts, academics, workers and clergy gave testimony regarding the practices of L.A.’s grocery industry, the report describes the growing disparities between the industry’s treatment of L.A.’s better off and poor communities.  The report presents evidence that LA supermarket chains ignore and mistreat the area’s low-income communities. The Alliance expects to propose citywide legislation that would establish uniform standards for grocery stores in Los Angeles, ensuring that low income neighborhoods receive more equitable treatment.

Federal Trade Commission. Marketing Food to Children and Adolescents A Review of Industry Expenditures, Activities, and Self-Regulation. A Report to Congress. Washington, D.C.: Federal Trade Commission, July 2008.  Available in [pdf]

From the FTC press release on the report:
“The Federal Trade Commission today announced the results of a study on food marketing to children and adolescents. The report, Marketing Food to Children and Adolescents: A Review of Industry Expenditures, Activities, and Self-Regulation, finds that 44 major food and beverage marketers spent $1.6 billion to promote their products to children under 12 and adolescents ages 12 to 17 in the United States in 2006. The report finds that the landscape of food advertising to youth is dominated by integrated advertising campaigns that combine traditional media, such as television, with previously unmeasured forms of marketing, such as packaging, in-store advertising, sweepstakes, and Internet. These campaigns often involve cross-promotion with a new movie or popular television program. Analyzing this data, the report calls for all food companies “to adopt and adhere to meaningful, nutrition-based standards for marketing their products to children under 12.”

Kolish ED, Peeler CL.  Changing the Landscape of Food and Beverage Advertising: The Children’s Food and Beverage Initiative in Action.  Arlington, VA: Council of Better Business Bureaus, July 2008.  Available at: www.nestle.com

From the Executive Summary:
During July through December 2007, the six companies scheduled to implement during this period, Campbell Soup Company, The Coca-Cola Company, the Hershey Company, Kraft Foods Global, Inc., Mars, and Unilever, successfully implemented their pledges in which they committed either to not engage in child-directed advertising or to feature only better-for-you products in child-directed advertising.

  • No child-directed advertising. Based on our review, Coca-Cola, Hershey and Mars did not engage in child-directed advertising as they had pledged.
  • Advertising only for better-for-you products. Based on our review, Kraft limited all, and Campbell and Unilever limited virtually all, of their child-directed advertising to better-for-you products as specified in their pledges.

Campbell reported, and the BBB separately observed, that during the initial start up period, it had overlooked removing, primarily on its child-directed company-owned websites, a relatively small amount of content that referenced or displayed products that do not (or did not then) meet its nutrition guidelines. These problems have been remedied. Its television advertising, which represented a substantially larger amount of its media expenditures, was otherwise compliant with its pledge.

  • The BBB found that Unilever, while otherwise fully in compliance, had overlooked removing a couple of products, out of many, from its child-directed company-owned website. It has corrected this issue.

During July through December 2007, Burger King Corp., Cadbury Adams, General Mills, Kellogg Company, McDonald’s, and PepsiCo began the process of implementing their pledges. Many of them, ahead of schedule, implemented their pledges to a significant degree by limiting or changing what they advertised to children, or by early implementation of other parts of their pledges, such as product placement commitments.

Langlois, A. and Crossley, R.    Proof of the Pudding: Benchmarking Ten of the World’s Largest Food Companies’ Response to Obesity and Related Health Concerns. New York: JP Morgan,  April 2008. Available in [pdf]

In April 2008, JP Morgan Limited released a report in which it evaluated ten major food companies against a best practice framework developed by Insight Investment and the International Business Leaders Forum ‘HEAL’ partnership, published in 2007: ‘A Recipe for Success’.

The report includes the key components of a comprehensive corporate response to consumer health and obesity challenges. All companies were initially evaluated on the basis of their public disclosure and assigned a score for the quality of reporting: sources used included annual reports, SEC filings, corporate responsibility reports or similar, websites.

Researchers offered to meet with managers of all the companies to discuss initial findings and provide a comprehensive explanation of their strategies and program. Seven companies took the opportunity to meet while Cadbury, Heinz and Kraft were not in a position to meet. Final analysis and score for performance completed on the basis of additional information provided in company meetings. Companies sent final provisional scores and offered the opportunity to review and provide additional information, which several did.

Marin Institute.  Why Big Alcohol Can’t Police Itself A Review of Advertising Self-regulation in the Distilled Spirits Industry.  Marin Institute, September 2008.  Available in [pdf]

In this September 2008 report, the Marin Institute analyzes the Distilled Spirits Council of the United States (DISCUS) Code of Responsible Marketing Practices reports from 2004-2007. The Federal Trade Commission relies upon a system of voluntary self-regulation to ensure responsible marketing practices by the alcohol industry. This report publishes for the first time a systematic review of the DISCUS oversight process, and concludes that the process is inherently biased and consistently fails to protect the public from irresponsible advertising.

National Cancer Institute.  The Role of the Media in Promoting and Reducing Tobacco Use.  NCI Tobacco Control Monograph Series. No 19.  Washington DC, National Institutes of Health, July 2008.  Available in [pdf]

src=”uploads/images/old_archives/img/clip_image012_0000.gif” alt=”Role of the Media in Promoting and Reducing Tobacco Use” hspace=”10″ vspace=”5″ width=”131″ height=”197″ align=”right” />Summarized from page vii of report:  This 684 page report is the most current and comprehensive distillation of the scientific literature on media communications in tobacco promotion and tobacco control. It synthesizes findings from the disciplines of marketing, psychology, communications, statistics, epidemiology, and public health and was compiled by five scientific editors, 23 authors, and 62 external peer reviewers. The report has six main parts. Part 1 frames the rationale for report’s organization and presents the key issues and conclusions of the research as a whole and of the individual chapters. Part 2 explores tobacco marketing—the range of media interventions used by the tobacco industry to promote its products, such as brand advertising and promotion, as well as corporate sponsorship and advertising. This section also evaluates the evidence for the influence of tobacco marketing on smoking behavior and discusses regulatory and constitutional issues related to marketing restrictions. Part 3 explores how both the tobacco control community and the tobacco industry have used news and entertainment media to advocate their positions and how such coverage relates to tobacco use and tobacco policy change. The section also appraises evidence of the influence of tobacco use in movies on youth smoking initiation. Part 4 focuses on tobacco control media interventions and the strategies, themes, and communication designs intended to prevent tobacco use or encourage cessation, including opportunities for new media interventions. This section also synthesizes evidence on the effectiveness of mass media campaigns in reducing smoking. Part 5 discusses tobacco industry efforts to diminish media interventions by the tobacco control community and to use the media to oppose state tobacco control ballot initiatives and referenda. Finally, Part 6 examines possible future directions in the use of media to promote or to control tobacco use and summarizes research needs and opportunities.

United Food and Commercial Workers International Union.  The Two Faces of Tesco.  Washington, D.C.: United Food and Commercial Workers International Union, June 2008. Available in [pdf]

From the press release for the report:
In June 2008, the United Food and Commercial Workers Union, a US union representing 1.3 million workers in the retail food market, launched a UK campaign to expose The Two Faces of Tesco. The report examines how Tesco operates in the United Kingdom, its home base, and the United States, and compares Tesco policies and rhetoric with its practices.

At a London press launch chaired by UK Member of Parliament Jon Cruddas the union said that it is stepping up a campaign already begun in the United States to shame Tesco to talks on union recognition and employee pay and benefits.

The UFCW seeks to represent some of the lowest-paid and least secure retail workers in the USA, more than half of whom are women, and has been seeking talks with Tesco for two years since the world’s third-largest retailer announced its entry into the US grocery market. All attempts have so far fallen on deaf ears, reports the UFCWU, and Tesco launched its chain of Fresh & Easy supermarkets in 2007 as non-union stores. UFCW says that it is seeking the chance for dialogue, to build the same constructive partnership that Tesco enjoys in the UK with the shop workers’ union USDAW.

Tracking on Corporations and Health

Those seeking to modify corporate practices that harm health often have to track changes in corporate or government policy to assess their progress. Here, Corporations and Health Watch describes a few databases and websites useful for tracking local and nation policy and the social responsibility performance of major corporations.

Tracking local policies:

Looking for policies to propose to solve a local problem related to food industry practices that reduce access to healthy food? Visit Prevention Institute’s Local Policy databasean online resource of local policies that can improve opportunities for healthy eating and physical activity. For example, a search for policies on unhealthy foods located 21 specific local policies, mostly in California, enacted to reduce promotion of unhealthy foods.

 

Tracking federal legislation:

Open Congress tracks legislative proposals and bills on various issues and industries. Its website explains different ways to use the site. For example, OpenCongress bill pages bring together news coverage, blog buzz, insightful comments, and more. Linking to OpenCongress thus gives readers access to the big picture as well as the official details on specific legislative proposals. If you write a blog post about a bill and include the official title (for example, H.R.800), then a link to your blog post will appear on that bill page. Another section shows the most-viewed bills, or hot bills by issue area. The site includes one-click sharing to Digg, StumbleUpon, Facebook, e-mail a friend, and more. It also allows visitors to find their members of Congress and to track their actions and what people are saying about them.

To illustrate topics of interest to Corporate and Health Watch readers, visitors can track legislative proposals on the following topics, among many others:

Alcohol taxes
Automobile industry
Firearms
Food industry
Pharmaceutical research
Tobacco industry

 

Tracking corporate responsibility:

Several organizations have ranked corporations on their social responsibility.

Fortune Magazine ranks 100 of the Fortune 500 on business responsibility.

The Ethics & Policy Integration Centre provide a user-friendly resource for tracking US and emerging global standards in corporate responsibility. It includes sections on environmental and human righs standards, but not health or consumer protection standards.

Corporate Responsibility Index The British group Business in the Community’s CR Index is the United Kingdom’s leading benchmark of responsible business. It helps companies to integrate and improve responsibility throughout their operations by providing a systematic approach to managing, measuring and reporting on business impacts in society and on the environment. Each year the CR Index lists and rates the top 100 companies in the UK.

 

Tobacco and the 2008 Presidential Election

With all the political differences between Barack Obama and John McCain, few voters are likely to pay much attention to their differences on tobacco policy. Yet tobacco will continue as the nation and world’s top killer for the next few decades, making tobacco policy an important influence on health. In this report, Corporations and Health Watch reviews the major tobacco issues that the next President will face and analyzes the positions of Senators Obama and McCain on these subjects.

Tobacco decisions for the next Administration

After 2009, the President and Congress will need to decide several questions including:

  • Should the Food and Drug Administration be given the authority to regulate tobacco?
  • Should the federal government raise the excise tax on tobacco?
  • Should the United States ratify the global treaty that seeks to reduce the health burden from tobacco?
  • Should the Federal Trade Commission set new standards for tobacco marketing?
  • What should be the expectations of future Supreme Court justices on such issues as corporate rights, commercial free speech, and the government’s responsibilities for public health?

FDA and tobacco Congress is currently considering legislation to give the Food and Drug Administration oversight of tobacco products. According to the New York Times, the bill calls for the establishment of a new center for tobacco regulation within the F.D.A., gives the agency the authority to regulate the content of tobacco products and bans candy-flavored cigarettes. Recently, legislators have debated whether or not to also regulate menthol in tobacco. The Congressional Black Caucus has opposed a plan to drop menthol from the list of regulated additives, arguing that menthol cigarette advertising targets Black smokers and may exacerbate tobacco’s adverse health impact. The bill calls for the new FDA tobacco unit to be financed by tobacco industry fees projected at more than $5 billion over the next 10 years.

The FDA bill has bipartisan support, with more than 50 Senate and 215 House sponsors. Some Republicans have threatened to block further consideration of the bill and President Bush has not supported it. Big Tobacco has split on the bill, with Philip Morris endorsing it, in part, analysts say, because it will help PM consolidate its position as industry leader by restricting additional advertising. Reynolds American, the second largest tobacco company, opposes the FDA bill and has launched an advertising campaign charging that the FDA lacks the capacity to take on new responsibilities. The TV ads use a vaudeville style plate spinner to make the point that the FDA already has too many responsibilities on its plate.

Federal excise tax on tobacco Currently, the average state excise tax on tobacco is $1.13 (generating $14.5 billion in annual revenue), while the federal excise tax is 39 cents a pack (for annual revenues of $7.3 billion) (www.ryomag.com). Last year, President Bush vetoed the child health insurance bill that included a substantial hike in taxes on cigarettes. The next President and Congress will be hard pressed to find the revenues needed to support rebuilding public health and health care programs. In the current political and economic climate, where new taxes are opposed by many constituencies, tobacco taxes offer a popular source for new income.

Framework Convention on Tobacco Control In 2005, the Framework Convention on Tobacco Control (FCTC), the world’s first public health treaty, became international law. The treaty requires ratifying countries to enact proven measures to reduce tobacco use and its public health and economic burdens.

While the United States joined 167 nations in signing the FCTC, President Bush has yet to send the treaty to the Senate for ratification. In April 2008, Russia ratified the treaty, leaving the United States virtually alone among major nations that have not yet ratified. The next President and Senate will have to decide whether to maintain or change that status.

Federal Trade Commission and Tobacco Currently the Federal Trade Commission provides oversight of tobacco advertising. In the current administration, the FTC has generally favored industry positions on regulation of marketing. While changes in the FDA role may lead to changes in the FTC mandate, a new President and Congress could beef up the FTC. Through appointments, legislation and public pressure, the FTC could again become a force in tobacco control, as it had been at various points in the 1960s.

Supreme Court appointments In a recent analysis of the Supreme Court published in the New York Times magazine, George Washington University law professor Jeffrey Rosen observed that the current court is more pro-business than any in recent history. Even its more liberal members, he writes, regularly support corporate over consumer interests, a trend he attributes to a concerted 35 year effort to transform the court into the most consistently business-friendly branch of government. In 2007, for example, the Supreme Court over-turned an Oregon court’s $79.5-million punitive damages judgment against Philip Morris for its marketing of tobacco; Justice Stephen Breyer, one of the more liberal justices, wrote the majority opinion).

Any tobacco issues related to the FDA, federal taxation, changes in FTC policies or practice, commercial free speech, global treaties, liability litigation or other issues will likely eventually make their way to the Supreme Court. Thus, who the next President appoints and the Senate approves to sit on the Supreme Court will have a major influence on federal oversight of the practices of the tobacco industry. On Jan. 20, 2009, six of the nine Supreme Court justices will be over the age of 70.

McCain and Obama on Tobacco

Whoever wins the 2008 Presidential election, the next occupant of the White House will be a less dependable friend of the tobacco industry than its current resident. As Paul Billings, vice president of national policy advocacy for the American Lung Association, observed, This administration hasn’t been particularly positive on a tobacco-control agenda. Box 1 shows the responses the two candidates provided to the American Cancer Society Cancer Action Network’s (ASC CAN) question on tobacco control.

ACS CAN QUESTION: TOBACCO CONTROL

As president, will you work with Congress to enact legislation (specifically, S. 625/H.R. 1108) to rein in the most egregious manufacturing and marketing practices of the tobacco industry, and will you substantially increase the federal tobacco tax to help improve public health, save lives, and protect children from a lifetime of smoking?

ANSWER: John McCain, Republican
Responses provided by candidate

 John McCain has consistently supported regulation of tobacco products by the Federal Drug Administration and is an original cosponsor of S. 625, the Family Smoking Prevention and Tobacco Control Act. He also was a leading voice in Congress calling on tobacco companies to cease marketing campaigns for tobacco products that target children, such as the Joe Camel campaign. John McCain does not propose to increase tobacco taxes, believes that the more efforts should be made to provide educational and preventive media campaigns to discourage any American from starting to smoke, and will work to make smoking cessation programs more widely available.

ANSWER: Barack Obama, Democrat
Responses provided by candidate

I am a cosponsor of S.625 and support greater tobacco regulation at the federal level. In addition, I was an ardent supporter of reauthorization of the Children’s Health Insurance Program, which included a significant increase in the federal tobacco tax. As president, I will also increase resources for public health programs that tackle smoking, particularly for programs targeting children, individuals with mental illness and other vulnerable populations.

ANSWER: ACS CAN

ACS CAN, along with the prestigious Institute of Medicine and the President’s Cancer Panel, strongly supports giving the US Food and Drug Administration authority to regulate the production and marketing of tobacco products. Today, the tobacco industry markets its deadly products to children with impunity. Every day 4,000 kids try their first cigarette 1,000 of them go on to become regular smokers. Enacting S. 625/H.R. 1108 will prevent more kids from smoking and it will save lives. ACS CAN also supports substantially increasing the federal tobacco tax because we know that every 10% increase in the cost of a pack reduces youth smoking by 7% and overall cigarette consumption by 4%. 87% of lung cancer deaths are caused by tobacco use and more than 400,000 Americans still die from tobacco related causes every year. Sensible regulation of the tobacco industry and increasing cigarette taxes will save lives.

Credit: American Cancer Society Cancer Action Network

Candidates responses to surveys provide one source of information on their positions should they be elected; another comes from their legislative voting record.

McCain’s Record on Tobacco

In the late 1990s, Senator McCain led an ultimately unsuccessful effort to give the FDA a mandate to regulate tobacco in exchange for protecting the tobacco industry against liability claims. In retaliation, the tobacco industry helped to fund negative ads against McCain in the 2000 South Carolina primary election. His loss in that state helped to force him out of the 2000 race. Currently, McCain supports legislation to give the FDA the power to regulate tobacco although he has not spoken out forcefully on the bill.

In the past, McCain has also supported increases in excise taxes on tobacco. In 2007, however, with President Bush, he voted against a children’s health insurance bill that was funded in part by an increase in the federal tobacco excise tax, a funding source McCain now opposes.

Senator McCain has promised to appoint conservative Supreme Court Justices, pointing to Justices Samuel Alito, John Roberts and Antonin Scalia as models. As Steven G. Calabresi and John O. Mcginnis, law professors at Northwestern University, observed in an op ed in the Wall Street Journal, On judicial nominations, [McCain] has voted soundly in the past from Robert Bork in 1987 to Samuel Alito in 2006. It seems unlikely that a President McCain would appoint Justices likely to change the pro-business slant of the current court.

While the tobacco industry has not provided much support to Senator McCain’s Presidential campaign, former tobacco industry lobbyists play key roles in his campaign. Charlie Black, a top campaign aide, was formerly director of BKSH and Associates, one of Washington’s most powerful lobbying groups. According to Open Secrets, since 1998 BKSH earned almost $1.3 million in lobbying fees from Philip Morris. Black’s wife, Judy Black, also an adviser to McCain, was a former executive of the Tobacco Institute, the research arm of the tobacco industry until the Master Settlement Agreement forced its dissolution. Black rejects charges that his former work for tobacco companies disqualifies him to work on McCain’s campaign. I think you can change professions and unless you did something unethical or criminal, your past profession should not be injected into the candidate’s campaign, he said. It’s absurd.

Obama’s Record on Tobacco

Senator Barack Obama has recently quit smoking, claiming that his wife would not let him run for President until he did. His policy positions on tobacco, however, date back to his time in the Illinois state Senate. According to a recent review of Obama’s legislative record on tobacco by Clifford Douglas, the Executive Director of the University of Michigan’s Tobacco Research Network, Barack Obama has:

  • With nine other Senators called on President Bush to send to the Senate for ratification the Framework Convention on Tobacco Control
  • Served as one of the original co-sponsors of legislation to give the FDA the authority to regulate tobacco products and marketing
  • Voted in support of the Display of Tobacco Products Act that makes it illegal to sell or give away tobacco products in self-service settings
  • Co-sponsored an Illinois state bill to use money from the Tobacco Settlement Recovery Fund to support a comprehensive tobacco use prevention program.

None of Obama’s current staff have been found to have worked for the tobacco industry and Obama voted against confirmation of Supreme Court Justices Alito and Roberts. In a recent analysis of the Presidential candidates positions on Supreme Court appointments in the Columbia Journalism Review, Zachary Roth wrote:

For instance, on the issue of the appropriate balance between corporate and individual rights: the press should make clear that Obama’s appointees, in keeping with his desire for empathy, can be expected to take a broader interpretation of laws designed to protect individuals; while McCain’s, if they are indeed in the Roberts-Alito mold, will interpret these laws more narrowly, and more often come down on the side of corporations.

However, whether Barack Obama will appoint Supreme Court Justices (or whether the Senate will confirm them if he does) who can reverse the pro-corporate tilt of the current court and restore a more balanced consideration of the rights of consumers and public health remains an open question.

2008 Election opportunities for tobacco control advocates?

In summary, the 2008 Presidential election campaign offers voters two major party candidates who are likely to provide somewhat more support for tobacco control than the current administration. Unfortunately, it seems unlikely that tobacco control will surface as a major campaign issue. By understanding the similarities and differences between Senators McCain and Obama on tobacco, by linking the issue of tobacco control to debates on health care policy, and by encouraging the candidates and the media to focus on their plans for the Supreme Court, tobacco control advocates may find some windows of opportunity to advance their cause.

View CHW’s coverage on Corporations, Health and the 2008 Presidential Race: Part 1: Following the Money
Part 2: Clinton, Obama and McCain on the Role of Corporations
Part 3: Clinton, McCain, Obama and the Food Industry
Part 4: Fixing the FDA: Options for the Next President

Corporate Targeting and the Impact of Corporate Practices on Socioeconomic, Racial/ethnic, Gender and Age Inequities in Health

Selected Peer-reviewed Articles

A small but growing number of studies examine how corporate practices influence health inequities. Studies have described and analyzed how corporations target selected populations for marketing of unhealthy products, assessed the impact of these practices on differences in health behavior and health, and explored other ways that corporate decisions maintain or exacerbate health disparities.

Here Corporations and Health Watch summarizes a few of these recent reports and invites readers to submit additions to the list for subsequent posting.

 

Baker EA, Schootman M, Barnidge E, Kelly C. The role of race and poverty in access to foods that enable individuals to adhere to dietary guidelines. Prev Chronic Dis.2006; 3(3):A76.

Analyzes the results of an audit of community supermarkets and fast food restaurants to assess the location and availability of food choices that enable individuals to meet the dietary guidelines established by the U.S. Department of Agriculture. The researchers used supermarket and fast food restaurant audit tools to assess the availability of healthy food choices in the urban area of St. Louis, Missouri. The researchers found that two factors (race and income) are associated with the location of food outlets and the selection of foods available. Individuals living in mixed or white high-poverty areas and in primarily African American areas are less likely to have access to foods that would enable them to make healthy food choices. The researchers recommend collaborations with the business community and political structures to make it economically viable to provide equal access to healthy food choices.

 

Brody H, Hunt LM. BiDil: assessing a race-based pharmaceutical. Ann Fam Med. 2006; 4(6): 556-60.

Analyzes scientific evidence on BiDil, the first drug approved by the Food and Drug Administration to be marketed to a single racial-ethnic group, African Americans, for the treatment of congestive heart failure. The authors discuss the problems that can arise when race is viewed as a biological-medical construct, leading to an overly simplistic assumption of a racial and hence presumed genetic difference while obscuring the “economic, social, cultural, and ethical issues lurking in the background.” The authors predict that the manufacturer will launch a publicity campaign targeting African Americans, and that family medicine doctors will be asked by their patients for the new “for blacks only” medication.

 

Freudenberg N, Galea S, Fahs M. Changing corporate practices to reduce cancer disparities. J Health Care Poor Underserved. 2008; 19(1):26-40.

Reviews data on disparities in cancer morbidity and mortality in the United States, and reviews evidence on corporate practices contribute to cancer risk behavior, incidence, and cancer disparities. The authors propose that the practices of the tobacco, alcohol and food industries be considered as modifiable social determinants of health. The authors conclude with recommendations for research, practice, and policy that would lead to what they term “less carcinogenic” corporate practices.

 

Kwate N O A. Fried chicken and fresh apples: Racial segregation as a fundamental cause of fast food density in black neighborhoods. Health and Place 2008;14:32-44.

Analyzes pathways by which racial segregation contributes to higher density of fast food outlets in Black neighborhoods in US. The author proposes that population characteristics, economic characteristics, physical infrastructure and social processes of Black neighborhoods each contribute to creation of “localized geographic areas for targeting by fast food corporations and operators.”

 

Kwate NO, Lee TH. Ghettoizing outdoor advertising: disadvantage and ad panel density in black neighborhoods. J Urban Health. 2007;84(1):21-31.

 

Investigates correlates of density of outdoor advertising in predominantly African American neighborhoods in New York City. Authors found that that black neighborhoods have more outdoor advertising space than white neighborhoods, and these spaces disproportionately market alcohol and tobacco advertisements. By linking census data with property data at the census block group level, investigators found that two neighborhood-level determinants of ad density were income level and physical decay.

 

Macdonald L, Cummins S, Macintyre S. Neighbourhood fast food environment and area deprivation-substitution or concentration? Appetite. 2007l;49(1):251-4.

Investigates associations between area deprivation and the location of the four largest fast-food chains in Scotland and England. The authors report statistically significant increases in density of outlets from more affluent to more deprived areas for each individual fast-food chain and all chains combined. They conclude that these findings support a “concentration” effect whereby environmental risk factors for obesity appear to be ‘concentrated’ in more deprived areas.

 

Monsivais P, Drewnowski A. The rising cost of low-energy-density foods. J Am Diet Assoc. 2007; 107(12): 2071-6.

Discusses the results of a study on the energy density and retail prices of 372 foods and beverages in major supermarket chains in the Seattle, WA metropolitan area in 2004 and 2006 (energy density and prices were calculated in terms of $/100g and $/1,000 kcal). The researchers discuss the role of lower energy-density foods as a strategy for managing overweight and obesity. The two-year price change for the least energy-dense foods was +19.5% whereas the price change for the most energy-dense foods was -1.8%. The researchers suggest that the lower price of energy-dense foods and the resistance of energy-dense foods to price inflation may help explain why the highest rates of obesity in the United States are observed among those with limited economic means.

 

Morrison MA, Krugman DM, Pumsoon P. Under the radar: smokeless tobacco advertising in magazines with substantial youth readership. Am J Public Health. 2008; 98(3): 543-48.

Reviews the level of advertising of smokeless tobacco products before and after the Smokeless Tobacco Master Settlement Agreement (STMSA). The researchers determined that the STMSA appears to have had a limited effect on adolescents’ exposure to the advertising of smokeless tobacco in magazines with high youth readership. The researchers determined that adolescent boys (aged 12-17) are at greatest risk for exposure to smokeless tobacco advertisements.

 

Primack BA, Bost JE, Land SR, Fine MJ. Volume of tobacco advertising in African American markets: systematic review and meta-analyses. Public Health Rep. 2007; 122(5): 607-15.

Reviews the peer-reviewed literature on the density of pro-tobacco media messages. Of the studies identified for inclusion, 11 met the eligibility criteria for the current review. The researchers pooled the results of these studies in a meta-analysis and conclude that African Americans are exposed to a higher volume of pro-tobacco advertising. The researchers also cite evidence demonstrating that African Americans bear the greatest morbidity and mortality burdens due to smoking, and that exposure to pro-tobacco media messages predicts cigarette smoking.

 

Schor JB, Ford M. From Tastes Great to Cool: Children’s Food Marketing and the Rise of the Symbolic. Journal of Law, Medicine & Ethics. 2007; Spring issue on Childhood Obesity: 10-21.

Discusses the increasing participation of children in the consumer markets, their heavy media use and exposure to high levels of advertising. The researchers discuss deteriorating diets and rising obesity, as well as the shift in children’s food advertisements from product attributes to symbolic messages. The researchers cite studies that demonstrate that exposure to junk food marketing is much higher for low-income children as well as racial and ethnic minority children, groups that also have higher rates of obesity.

 

Thompson DA, Flores G, Ebel BE, Christakis DA. Comida en venta: after-school advertising on Spanish-language television in the United States. J Pediatr. 2008; 152(4): 576-81.

Analyzes the content of food and drink commercials aired during after-school hours (3 to 9 p.m.) on two Spanish-language television stations in the United States. The researchers found that children viewing Spanish-language television in the United States after school are exposed to food and drink commercials, mostly advertising unhealthy foods, including fast foods and sugared drinks. The researchers propose that food and beverage advertising to children via Spanish-language television may contribute to the high rates of obesity among Latino children.

 

Yerger VB, Przewoznik J, Malone RE. Racialized geography, corporate activity, and health disparities: tobacco industry targeting of inner cities. J Health Care Poor Underserved. 2007; 18(4 Suppl): 10-38

Reviews more than 400 internal documents from the tobacco industry to explore the ways in which the tobacco industry targeted inner cities populated predominately by low-income African American residents in the 1970s-1990s. The authors cite studies demonstrating that smoking rates remain higher among the poor, the less educated and other underserved populations, despite significant reductions in the overall smoking rate in the United States. This archival analysis demonstrates how the tobacco industry’s promotion activities and the “menthol wars” fought by tobacco companies in America’s inner-cities have contributed to the tobacco-related health disparities that we observe today.

Commentary: Shifting priorities in public health: from changing lifestyles to changing political, economic, and social circumstances

Public health researchers seeking to focus greater attention on the role of corporate practices in health and disease often encounter the argument that the only significant modifiable determinant of health is lifestyle.  In this commentary, social epidemiologist Sandro Galea, MD, DrPH, Associate Professor at the University of Michigan School of Public Health makes the case for a broader perspective.

The typical public health observational study goes something like this.  We identify a disease of interest.  We then try to figure out if an exposure is indeed associated with this disease. We conduct a study and collect data from participants.  We then use a variety of increasingly sophisticated analytic tools to isolate the relationship between the exposure of interest and the disease.  Once we have identified such an association with some confidence, we recommend a behavior change that will limit exposure to that particular factor.  For example, here is the conclusion from a recent, well done study aimed at understanding several factors that may cause cardiovascular disease: “strategies should focus on reducing obesity, in particular through physical activity, elimination of cigarette smoking, and moderation of alcohol intake” (1).

In other words, to reduce heart disease, we need a lifestyle change, to eat less, exercise more, and smoke less, in order to become healthier.  These types of conclusions come from peer-reviewed academic papers published in reputable public health journals. In many ways, these recommendations arise naturally and logically from the dominant public health paradigm.  We understand the factors that make us sick and now all we have to do is to change the way we live so that we are no longer exposed to those factors.

Although it is seldom stated in this manner, the public health literature veritably shrugs in disbelief when contemplating these issues, suggesting “how could they possibly keep smoking (or drinking too much etc) when we tell them over and over how bad that is for their health?” Or, “how could they possibly continue having such an unhealthy lifestyle?”

Tobacco as a Lifestyle Problem

Let’s look back at one of the great triumphs of modern public health science to provide us with hints about our lifestyle and whether we truly can do something about it.  All students of public health well know the details of what the Centers for Disease Control and Prevention (CDC) rightly identified as modern pubic health’s greatest triumph—the identification of tobacco smoking as a risk for disease(2).  In the middle of the twentieth century a few physicians-turned-epidemiologists used follow-up cohort studies to show that cigarette smoking was associated with lung cancer and heart disease.   These studies led to other comparable studies confirming these findings.  There was opposition to this observation at first, primarily from cigarette companies, but, with the production of the surgeon general’s report on smoking in 1964, the fact that smoking causes poor health in many forms became accepted within public health circles.  What followed of course was a dramatic burgeoning public health effort to help eliminate smoking.  A large industry grew around health education programs to teach all of us about the adverse consequences of smoking and countless education programs aimed to help smokers quit.

Smoking prevalence dropped throughout North America from 42% in 1965 to 25.5% in 1990 to a current prevalence of approximately 20.8% percent (3).

Clearly, public health research and practice “saved the day”.   Through careful empiric research, we were able to identify a health menace and we have, ever since, been devoting energy to help eradicate this menace. One cannot walk through any major US urban area without seeing a plethora of health education messages touting the evils of smoking, offering Quit-Lines and other aides to quite smoking and, increasingly, rather horrifying pictures of the pathologic consequences of smoking aimed at scaring us into not smoking.

But we, or at least 1 in every 5 of us, keep smoking. In fact, we keep participating in many of these factors that we surely must by now know cause poor health, including 1 in 5 of us drink too much on a regular basis, 1 in 3 of us are overweight, and 1 in 3 of us own firearms (4).  All of these factors are well recognized to be among the leading causes of death in this country (5).

Why do people choose unhealthy lifestyles? 

Which then brings us to the issue at hand. Why is it that so many patently harmful factors in our lifestyle continue despite public health’s valiant effort?   The existing literature suggests three common answers.  First, some posit that there are psychological reasons, including pleasure in risk taking and defying conventional wisdom, in continuing to embrace unhealthy lifestyles.   Second, some argue that public health professionals are not as good as we need to be at conveying what unhealthy lifestyles should be avoided. A third explanation asserts that ultimately people do not care much about being healthy and would rather do as they please without regard for health.  All these can be summarized to say that fundamentally, people choose the lifestyle they want, irrespective of what public health might say.

While these (and other)  explanations all have some validity,  they should matter little to us as public health professionals because a focus on lifestyle is simply not the most efficient or effective approach for public health to take.  Why?

Perhaps another example, one that contrasts with the previous smoking one, illustrates the point. Another of the CDC’s great recent achievements in public health is the reduction in motor vehicle injuries and deaths (2). As the automobile took the US by storm by the middle of the twentieth century, the rates of motor vehicle accidents and deaths were soaring. There were 93,803 unintentional motor vehicle related deaths in 1960, for example (5).  Clearly, our lifestyle choice to drive was also killing us. One approach would have been for the public health establishment to urge every American to drive less, to walk instead or take mass transit – to change their transportation life style.  But that is not what happened.

Instead, a consumer movement emerged that demanded the automobile industry to make safer cars  and Congress passed laws to make that happen, usually over the objection of the automobile industry and with significant compromises.   For example, Ralph Nader’s Unsafe at any speed (1965) resulted in changes that substantially changed the contribution of motor vehicle accidents to our burden of disease morbidity and mortality.  However, in stark contrast to the tobacco example, the focus of the changes aimed at reducing car-related disease was not on the “users” of the car but rather on the circumstances of the driving.  Certainly driver education improved, but it is widely recognized that the greatest contributor to the change in car-related morbidity and mortality were safer cars, safer roads and better enforcement of traffic regulations aimed at making those collisions that were inevitable less injurious. As a result, although there are now more than 200 million drivers on the roads on a regular basis, compared to under 90 million in 1960, the rates of motor vehicle accidents in the US is less than 1.5 per 100 million vehicle miles traveled compared to approximately 5 per 100 million vehicle miles traveled in 1960 (6, 7).  In other words, we did not really change our lifestyle (driving) at all (in fact, we are driving much more than ever), but still improved our health. We can argue about whether a different approach might have led to more sustainable and better environmental outcomes, but in this case changing corporate practices rather than lifestyle led to dramatic improvements in public health.

In contrast, until the last decade or so, tobacco control focused primarily on changing individual behavior.  As new policies were passed to ban smoking in public places and increase tobacco sales taxes, the declines in tobacco smoking accelerated, showing the value of integrating strategies to change individual lifestyle and policy.

Both these examples in fact reinforce the observation that changing lifestyles is immeasurably difficult, requiring not only efforts to change deeply held beliefs and practices one person at a time but also to continue to “treat”  the new recruits into tobacco use, or eating or drinking too much.  Thus, perhaps changing lifestyles should not be the point of what we do in public health but rather changing circumstances should be. Perhaps it is time to recognize that changing lifestyles is in fact very difficult and that a more efficient and effective approach would be to change the political, economic, and social circumstances within which  people live their life as they please, to the fullest. This strategy also acknowledges that people do not choose lifestyles in a vacuum but are influenced by corporate practices such as advertising and product design, by public policies, and by the “opportunity structures” of our market economy.

Objections to a critique of lifestyle

This argument can lead to complaints along three grounds.  First, some would object to leaving individuals to their own lifestyle choices within a healthier environment as insufficient given that some lifestyles are inherently injurious to self or others.  Second, some critics might assert that if public health were to take responsibility for the circumstances within which we live, it would contribute to a “nanny state”, highly unpopular in a country where individual autonomy is prized almost above all other virtues.  Third, some public health experts believe that it is outside our professional domain to seek to change economic, political, and social circumstances. In my view, each of these criticisms is in fact wrong. Let us tackle each one.

We cannot avoid dealing with lifestyles; some lifestyles are always harmful. It may seem that some lifestyles are simply harmful in an absolute sense, but is this really the case?  Let’s return to the cigarette example.  We now know that tobacco companies worked hard to make cigarettes more addictive to increase consumption and therefore profit. From the point of view of addictiveness and carcinogenicity, they are harmful by design.  To take another example, people choose high fat, high calorie food in part because that is what has been most advertised and made most available.  In these two cases, the health consequences of lifestyle “choices” are the direct result of efforts to make a profit.  With different food or tobacco policies, the default choices could be very different.  So what do public health professionals work to change—the environments and policies that make some lifestyle choices unhealthy or the behaviors themselves?

Public health cannot tackle political, economic, or social circumstances because that threatens individual autonomy. Would a public health focus on changing the circumstances within which we live mean that public health would reduce individual autonomy?  Of course it could but the critical point is that doing so would not be any different than what is already done to our individual autonomy by forces other than public health.  We do not choose the cigarettes we smoke—we smoke cigarettes that are made for us by corporations acting under a set of their own incentives (primarily to maximize profits) that are often not aligned with the goal of improving our health.  We often have little choice about the food we eat.  Recent research shows that those living in poor neighborhoods have more access to unhealthy foods and less to healthy ones. Not surprisingly, they then eat those available foods.  Similarly, for the most part drivers do not choose to drive in safer cars, on safer roads than we used to drive on 50 years ago. These choices are made for us by political, economic, and social forces that are larger than ourselves. It has always been so and it will always be so. Urging public health to tackle reshaping our circumstances would introduce a player among these forces that shape our circumstances whose interest is in the promotion of health rather than in the promotion of profit (as in the case of corporations) or electoral success (as in the case of political parties).  The choice is not whether parents should have sole rights to make health decisions about their children – our world is too complicated for that.  Rather, the question is who do Americans want looking out for their children’s health—public health professionals or McDonalds?  Public health professionals should welcome an opportunity to argue they will better protect autonomy than Ronald McDonald.

Public health simply is not equipped to tackle changing contexts. This third objection is a plaintive one—but what can public health do?  Public health arises from medicine, which is concerned with the health of individuals. The forces of public health are much weaker than are political, economic, or social forces.  How could we possibly compete?  It is self-evident that unless we try to compete we cannot succeed. It is also true that challenging contextual forces that shape health as a central focus would require substantial retooling of the public health profession.  It would require re-thinking how we teach our students, the goals and methods of professional practice, and the value of being well-regarded by all sectors of society.  But other professions have been able to conduct similar retooling. Why then not public health?  For example, many US State Attorneys General were, in the 1970s and 1980s focused on the eradication of organized crime.  This scarcely remains the focus on AG efforts nationwide today. In fact, AG efforts have been, in the past decade, much more focused on curtailing illegal financial sector activity than on what the AG offices used to work on a decade ago. Surely such focus shifting could not have been easy. But it happened, and arguably the law-abiding citizenry is better for it.

Another approach to public health is possible

Similarly, public health can decide that the old target, lifestyle, is no longer, or perhaps never was, such a fruitful target for our efforts, and move toward another target, the circumstances within which we live, the political, economic, and corporate practices that shape our environment, with the goals of effecting change here in order to promote the health of the public.   The objections to such an approach rest primarily on a lack of imagination on our part that we can indeed achieve a change in focus in the profession.  I argue that such a change is not optional, as much as necessary, for public health achievement in the twenty-first century.

Sandro Galea is the editor of Macrosocial Determinants of Health (Springer 2007) and can be reached at sgalea@umich.edu.

 

References

1.  Costanza MK, Cayanis E, Ross BM, Flaherty MS, Alvin GB, Das K, Morabia A. Relative contributions of genes, environments, and interactions to blood lipid concentrations in adult populations. American Journal of Epidemiology2005;161(8):714-724.

2. CDC. Ten great public health achievements–United States, 1900-1999. MMWR 1999;48:241-3.

3CDC. Surveillance for Selected Tobacco-Use Behaviors — United States, 1900-1994. MMWR 1994; 43: 5-6.

4.  Mokdad AH,  et al. Actual causes of death in the United States, 2000.  JAMA. 2004;291(10):1238-45.

5.  Okoro et al. Prevalence of household firearms and firearm-storage practices in the 50 states and the District of Columbia: findings from the Behavioral Risk Factor Surveillance System, 2002. Pediatrics. 2005;166(3):e370-e376

6.  CDC.  Achievements in Public Health, 1900-1999 Motor-Vehicle Safety: A 20th Century Public Health Achievement. MMWR 1999; 48(18);369-374.

7.  Fatality Analysis Reporting System.  Encyclopedia.  Available at http://www-fars.nhtsa.dot.gov/Main/index.aspx

 
 

Interview with Richard Daynard

In March 2006, the newsletter Informed Eating interviewed Richard Daynard, professor at Northeastern University School of Law.

Food activists often ask what lessons they can learn from the fight against Big Tobacco. In this interview, published in March 2006 in Informed Eating, a newsletter of food politics and analysis, Richard Daynard, a professor at Northeastern University School of Law, chair of the Tobacco Products Liability Project, and director of the Public Health Advocacy Institute’s Law and Obesity Project, describes his views on the similarities and differences between the public health advocacy on food and tobacco.

Public Health Advocacy on Tobacco and Guns Down Under and Beyond – An Interview with Simon Chapman

Simon Chapman is Professor of Public Health at the University of Sydney in Australia. He has studied and participated in public health advocacy on tobacco, guns, and other issues. He is a sociologist who wrote his PhD dissertation on the semiotics of cigarette advertising, and has written 10 books and major government reports and published more than 160 papers in peer- reviewed journals. His main research interests are in tobacco control, media discourses on health and illness, and risk communication. He teaches courses in Public Health Advocacy and Tobacco Control in the University of Sydney’s MPH program. He also serves as editor of Tobacco Control and was a key member of the Coalition for Gun Control that won the 1996 Australian Human Rights and Equal Opportunity Commission’s community Human Rights award. His new book, Public Health Advocacy and Tobacco: Making Smoking History will be released this September by Blackwell Press. A few months ago, Corporations and Health Watch founder Nicholas Freudenberg interviewed Chapman in his Sydney office. We publish here excerpts of that interview.

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.