Tuesday, September 15, 2009

Smoking Outside, A Public Health Threat?

The New York Times has been impressing me recently with its coverage of public health issues. Sure, health care reform makes that coverage pretty much a no-brainer, but today's front page article on the proposal to ban smoking outdoors in New York City definitely peaked my interest. It is part of the "Take Care New York Plan 2012" and includes other public health proposals in addition to banning smoking in public parks and beaches.

New York City has long been an early adopter of public health initiatives, such as eliminating trans-fat from prepared foods, improving menu labeling in fast food chains to include calorie counts, and banning smoking from nearly all indoor spaces.

The proposal, launched by the NYC health commissioner, Dr. Thomas A. Farley, to ban smoking from public, outdoor spaces is not without precendence, as the article points out:
"A number of municipalities — particularly in California — have banned smoking at outdoor parks, playgrounds and beaches. In 2007, Los Angeles extended its smoking ban, which already covered beaches and playgrounds, to include municipal parks. Later that year, Chicago banned smoking at its beaches and playgrounds, though smoking is still allowed in many parks."
Nonetheless, there is much controversy over the need for such a ban. What are its objectives?

On one hand, its objective may be to protect people from the deadly consequences of second-hand smoke. This has been the driving force behind indoor smoking bans, and is based in a preponderance of public health research and epidemiological literature. Yes, there was industry industry pushback, and many small businesses like bars were concerned about how it would impact their bottom line. But, in terms of public health, this policy was unanimously supported.

The idea to ban smoking in outdoor spaces may not be as cogent an argument if the goal is to reduce deaths and disease from second-hand smoke. Enclosed spaces, or areas where persons are required to be in close proximity to one another (and some outdoor spaces may fit the bill here, I am sure), seem to have the strongest evidence for such a policy recommendation.

A different objective may be to reduce consumption of cigarettes among smokers and/or to reduce the uptake of smoking among non-smokers. This objective would be better supported by the literature and social/behavioral research. It makes logical sense, as well. If you have fewer places where you are able to smoke, you will smoke fewer cigarettes and may be even more likely to quit smoking altogether (or at least try). Similarly, if you are unable to smoke in most places, you will probably figure its not even worth the effort to take it up in the first place.

This second objective is the one most likely of interest to the health commissioner, given that the second of the Plan's ten core indicators is "Adults who smoke." Thus, this reducing the number of smokers and preventing its uptake are a key area that the commission wants to tackle.

That being said, the Plan describes the outdoor smoking ban under the heading "Limit Exposure to Second-hand Smoke." Is this politics in action?

These two objectives illustrate how current research may be used to support a ban on outdoor smoking for some public health aims, and not others. The challenge is that both will illicit strong opposition. The first objective, if back with strong evidence, is the most politically acceptable public health aim. The second, may have more political contention -- though, I would like to think that reducing cigarette consumption among all New Yorkers would be a very laudable public health and political achievement.

So far NYC has been able to bring down the rate of smoking to 15.8% (in 2008) from 21.5% (in 2001), according to the article. This seems like a significant change to me (though I do not have the p-value to prove it), and one that should be applauded. I hope that their intervention strategies continue to be implemented in other cities and States across the country.

Should NYC continue its efforts to reduce tobacco consumption among its residents? Absolutely! Would this ban bring them closer to achieving that goal? I would expect so! Will it face extremely fierce opposition and hurdles in making it happen? No doubt.

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