Smoke Signals: Unpacking the Moral and Sociological Impact of Australia's Indoor Smoking Ban

I have written half the essay: Smoke signals: Unpacking the Moral and Sociological Impact of Australia’s Indoor Smoking Bans The health hazards associated with smoking, both primary and through second hand inhalation have been extensively documented. Smoking is still one of the largest preventable causes of death in Australia, leading to cardiovascular disease, lung disease, cancers and infections1,11. This has prompted increasing regulatory action against smoking in society, such as increases in taxation, smoke-free zones, advertisement bans and education campaigns2. It only seems natural then that this regulation would extend to banning smoking in indoor spaces as the next step towards a healthy society. This policy will be the primary focus of this essay. It has been well documented that the successes of smoke free zones and indoor smoking bans have seen a marked reduction in overall tobacco use in Australia3, however there is still ongoing debate and critique around its efficacy in reaching communities from low socioeconomic backgrounds and in its inabilities to cater to the entirety of Australia’s population4. In this paper I aim to analyse the validity and relevance of the indoor smoking ban policy to continue in its current form. I will firstly analyse the current ethical justifications of indoor smoking bans through paternalism and the harm principle and associated critiques. I will then outline the unequal distribution of smoking status amongst different socioeconomic classes, considering the policy through the lens of social determinants of health and discuss how they impact its efficacy. Using these points, I will argue that while the indoor smoking ban policy in its current form has a clear moral and ethical framework on which it stands, it still has room for improvement if it is to adequately meet the demands of a widening social inequity gradient in tobacco use. The introduction of smoke free zones has been highly successful in reducing both tobacco related burden of disease and tobacco use overall3. Specifically, in Australia, smoking in ‘enclosed public spaces’ like shopping centres, hospitals, schools, theatres, and planes, is banned in all its states and territories4. The positive impacts of these have been documented since its first implementation in 2006 and have shown to reduce the number of tobacco users overall in the last 15 years from 24% in 1992 to 11% in 20195. The introduction of indoor smoking bans was extended to the prison system in 2015, with all correctional facilities and complexes adopting this legislation6,8. A report by the Australian Institute of Health and Welfare showed a reduction of 10% of the prison entrants who were less likely to smoke after being released from a prison which banned smoking compared to a prison which allowed it6. It, however, must be noted that these reductions cannot be quantitively attributed solely to or as a result of indoor smoking bans but as a combined effort of all smoke reduction regulations. Despite all this positive impact however, the inequity in smoking behaviour amongst socioeconomic classes and the effectiveness of smoking bans is still up for debate. Tobacco use still remains stubbornly high amongst those groups who are the most impacted by tobacco harm. Parts of the community who are classed as lower on the socioeconomic scale, people in psychiatric settings, prisoners, people experiencing homelessness and the Aboriginal and Torres Strait Islander communities are all ranked as having almost double the rates of smoking prevalence amongst them with little to no reduction in their smoking rates in comparison to the above reports2,7,8. This begs to question whether the efficacy of such policies are still relevant in today’s society and whether reform is necessary to address the growing disparities in smoking rates. ETHICAL JUSTIFICATIONS FOR INDOOR SMOKING BANS THE HARM PRINCIPLE Firstly, the definition of public health and its various ethical, legal, and conceptual parameters and boundaries need to be essentially defined as it could prove to lay the grounds for the central inquiry of this essay and in doing so, we may provide a justification for the discouragement of smoking in enclosed spaces. While there are a number of influential definitions which have formed the basis of many policies, it is beyond the scope of this paper to determine the ‘most legitimate’ claim to what public health should pertain to. Instead for the sake of brevity I choose to use the broad, albeit eloquent definition proposed by Childress, in that, “public health is primarily concerned with the health of the entire population rather than the health of individuals, emphasising focus on the   complex interactions of behavioural, social and environmental factors in developing effective interventions”3(p830). Arguably, the principal justification of the indoor smoking ban is the basis of protecting non-smokers from the harm that second-hand smoke causes, forming the hallmark of public health strategies and has strong roots in the ‘harm principle’. In his seminal work as discussed by Oriola3, John Mill purported that “the only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others”3(p833). In other words, a power cannot be exerted on any person to prevent harm to himself, whether it is physical or moral but only to protect those around them, advocating absolute freedom of choice and sovereignty over one’s choices that concerns them and them only. It is now inviolable that non-smokers experience health consequences comparable to the smokers themselves through the inhalation of environmental smoke5. Therefore, it seems fairly straightforward in using the harm principle in support of the argument of indoor smoking prohibitions, in that it serves to protect the health of the people around the smokers. Furthermore, it could be argued that not only is the indoor smoking ban protecting the health of the public who share the space with smokers directly through protection from second hand smoke and associated illness, but also indirectly through protection of overall public interest and minimising excessive healthcare costs for those who will ultimately place a burden on an increasingly strained public health system3. Conversely and quite ironically, the harm principle does not play a role in protecting the smokers themselves, as it denotes that people have an absolute right over the actions impacting themselves solely9,10. Critics of this view often draw upon this point arguing that an application of something as forthright as the harm principle requires careful consideration on the unintended impact it may have on people who are marginalised in any give context 9,10. PATERNALISM In considering the ethical justifications of indoor smoking bans, it is essential to consider the paternalistic stance, albeit more controversial than the harm principle, offers another lens through which the hallmarks of public health are addressed. I have used the Vancouver style reference in this essay and will attach the references I want to use in the following documents. ? I need to write the rest of the essay using these points as below however I am a little stuck on the wording. I need a draft essay to edit it. The points remaining left to write: - Definition of paternalism. Distinguishing between ‘soft and hard’ and how the indoor smoking ban falls under the ‘hard’ paternalism stance. - Defend the previously mentioned criticism against the harm principle using this lens i.e. paternalism lends to protecting the smoker against harms of tobacco use for the good of their own health. - Criticisms of this can say that it is too broad, not taking into consideration the social determinants of health and inequities which may disadvantage the disadvantaged even further, providing a link to the next paragraph. INDOR SMOKING BANS IN RELATION TO RISING SOCIAL INEQUITY - It is not that the current policy has not justifiably contributed to the reduction of smoking hazards and ill health outcomes of Australians in the past, it is that the ‘public’ in which it is now targeting may be different – remembering that public health concerns the health of the entire population however would not be appropriate if the population in which it is targeting does not necessarily need the intervention i.e. high socioeconomic income individuals with higher quit rates and lower mortality. - This policy has had a huge impact in reducing the rates of smoking amongst middle to higher class people (justified through harm principle and utilitarianism) however, it is still rampantly high amongst people in low SES and Aboriginal and Torres Strait Islander communities and serves to widen the gap between the two. - Provide valid empirical evidence to support this claim. - Last paragraph to tie together concepts.