Air pollution and the public health agenda

You will have seen discussion boards where somebody points out that exhaust emissions are worse for you than passive smoking, and someone else says 'ah, but we need cars'! as if this were a good enough reason to ban something that we supposedly don't need, without any proof that it's damaging.

When I was growing up in the 1970s word had reached us in East Yorkshire that Glasgow had a poor health record. We were told that much of this was because of poverty, substandard housing and a damp climate. No one in those days told us that drinking and smoking was the cause or gave us that pearl of twenty-first century wisdom – that smoking causes health inequalities.

But in the corridors of power there is evidence of change going back twenty more years. (H/tip to Rose for the link.) Published in 2002, this link reports attempts to disguise the impact of air pollution on the London smog of 1952:

Delegates attending an international conference in London today to commemorate the 50th anniversary of the Great London Smog of 1952, which caused an estimated 12,000 deaths, will hear how governments from the late 50s onwards deliberately downplayed the huge threat to public health caused by air pollution, and sought to shift the blame firmly onto cigarette smoking instead.  

In 1953, Dr Guy Scadding, speaking on the television programme Matters of Medicine, had expressed a belief that air pollution was as much a factor in whether someone developed lung cancer as smoking, citing the significantly higher number of deaths from the disease among those living in polluted cities, as opposed to the countryside, and assuming that rates of smoking were likely to be similar in both populations. 

A few years later, in 1957, the Medical Research Council was planning to issue a statement saying although smoking was a significant cause of lung cancer, up to 30% of cases might be caused by air pollution. But the Cabinet committee on cancer of the lung, fearful of another political embarrassment which could be caused by stressing the air pollution connection, asked the MRC to reconsider its statement. On 31 May 1957 a modified version was published, which asserted that although it was likely that atmospheric pollution did play a role in lung cancer, it was 'a relatively minor one in comparison with cigarette smoking'.

 The clear conclusion?

'What was happening in this committee was a shift away from a concept of health and wellbeing related to an individual¹s environment, occupation, class or work, towards one focused strongly on that individual's responsibility for his or her health, which smoking came to symbolise. After the 1962 report, it was smoking and the type of public health which it epitomised which was to become the central public health issue. Smoking was something which the individual could do something about; air pollution was not,' explains Professor Berridge.

Public health, as far back as 1957, was to become judgemental. The medical establishment was already prepared to take an attitude on the issue, and suppress data that would inconvenience the public health message: 'take responsibility'. (Was this an early revolt against universal health provision free at the point of need?)

The medical establishment has appealed to corporations to take note that poor employee health is costing money. Hell, someone has to support them, and why not have a crack at those who support smokers, drinkers and the obese by offering them a livelihood?

Sometimes this smacks less of altruism than of a deliberate attempt to disenfranchise people. Usually, in fact.  Any health problem can be resolved by addressing personal issues (smoking, drinking ...). People are not expected to protest about the extent of air pollution (or any other health issue) because health politics is no longer the domain of those most affected by health inequalities. Their duty is to look after themselves so that their employers can make more money from them.

More on ASH Scotland's alliances

As if the Scottish Coalition on Tobacco were not enough, ASH Scotland also coordinates the Scottish Tobacco Control Alliance.

They also support what they call local alliances. The thoroughness of their briefings must be considered in light of their 27 staff (just take a look at their media briefing for the Lothians).

The resources put into attempting to reorder everybody's priorities so as to blame smoking for all ills, deaths and inequalities (who wants to live forever?) are significant. However, page 3 of SCTA's 2010 annual report shows that of the 119 or so member organisations involved with it, the largest groups are involved with NHS smoking cessation and NHS health promotion. It's a career move, rather than a popular cause.

SCTA holds events, has members and topics groups, produces a bulletin and annual report (all accessible from here), and has gained a grant from Cancer Research UK towards the formulation of what has become Scotland's tobacco control strategy. Their output includes a discussion of the new mental health guidelines, Smoke-free mental health services in Scotland – Implementation guidance at a meeting for mental health professionals in Glasgow in June (you get Learning Outcomes for attending too – all free of charge). Never mind that the then Scottish Government specifically exempted mental health services from the smoking ban when it was passed in 2005, and no reason has been offered for any change from this position, nor has any such change been endorsed by the public.

Sheila Duffy's latest (comments-free) blog post urges all parties to support a new tobacco control strategy (while announcing that most of the parties have promised this already). She had a column in today's Scotsman (20 April) that appeared as 'Platform' beside the editorials, claiming that tobacco control still had to eradicate the differences in mortality rates between Scotland's rich and Scotland's poor, and that continued support for Scotland's tobacco control was essential.

Impressive although all this networking is on one level, it's hard to see how it helps resolves any of the difficulties that face most Scots these days. Sheila Duffy's conclusion to her opinion piece in the Scotsman today concludes:

The challenge for our politicians is to reduce the health inequalities gap caused by smoking ...

An interesting economic analysis, that such inequalities are caused by smoking. Duffy is right to point out that higher mortality exists in more deprived areas. But this is not simply because people smoke: even if smoking is a factor, so is chronic unemployment, homelessness, anxiety and all the other consequences of being at the bottom of the economic heap. It's as if the powers that be are saying to the deprived: societal problems are too complicated to work out. But your problems will be marginally less severe if you don't smoke. So don't do it. You know it makes sense.

It's a top-down analysis. It's taken committed smokers out of 'polite society' too: they can no longer relax with peers and be seen to enjoy themselves in public places. It's made it harder for many smokers to assume positions of leadership, because the act of smoking has been so deliberately stigmatised. In the end it distorts all experience to the single plane of whether or not people smoke (see the discussion of the young mother on page 4 of the annual report).

It does all this very largely on government funding and with the blessing of all the main political parties in Scotland.

Of Scotland, Jamaica and health inequalities

Scotland saw a rash of stories today following this press release from ASH Scotland. The Courier warns starkly that 'anti-smoking targets will not be met'. The Scotsman says, Fear of Scots health divide as war on smoking fails poorest. (Did anyone really think a smoking ban would close the health inequalities gap? If there are more smokers at the bottom of the income scale, there will be more people suffering social disruption from those sections of society. The wealthy, even those who smoke, are relatively little inconvenienced by smoking bans if they have room to entertain at home. Being effectively marginalised from mainstream society does affect health: physical, mental and emotional.)

I enjoyed the take of Planet Politics on this situation. It confirmed my suspicion that all the smoking ban has managed to do was to 'rearrange the smoking deckchairs' (i.e. get people smoking at home instead of persuade them to stop smoking), rather than make any difference in anyone's health.

Indeed the ASH Scotland press release speaks of an 'increasing health inequalities gap'. That wasn't meant to happen, was it? Oh dear, the anti-smoking groups have been going on about health inequalities for years, but they just seem to be making things worse. Health inequalities are getting wider, not narrowing. I have to say that the idea that smoking causes health inequalities is somewhat blinkered, but that is what professional tobacco control advocates believe.

Meanwhile, Jamaica does not have a smoking ban yet and does not seem to have even announced one. But the Director of the Heart Foundation of Jamaica is clearly gunning for one. No apprehensions whatever about any adverse consequences. These words express plenty about the importance of narrowing health inequalities in the minds of ban advocates:

Those who continue smoking because of their addiction to the drug nicotine, an ingredient in cigarettes, will continue to do so in their homes, to the possible detriment of the health of those who live with them. But for non-smokers who enjoy the freedom of clean air and the health benefits of unpolluted lungs, smoking bans reduce exposure to second-hand smoke.  [my emphasis]

The bans effectively divide the interests of one section of the population from the rest. Non-smokers are more equal than everyone else.