Resisting Moralisation in Health Promotion

Health promotion efforts are commonly directed towards encouraging people to discard 'unhealthy' and adopt 'healthy' behaviours in order to tackle chronic disease. Typical targets for behaviour change interventions include diet, physical activity, smoking and alcohol consumption, sometimes described as 'lifestyle behaviours.' In this paper, I discuss how efforts to raise awareness of the impact of lifestyles on health, in seeking to communicate the (perceived) need for people to change their behaviour, can contribute to a climate of 'healthism' and promote the moralisation of people's lifestyles. I begin by summarising recent trends in health promotion and introducing the notion of healthism, as described by Robert Crawford in the 1980s. One aspect of healthism is moralisation, which I outline (alongside the related term moralism) and suggest is facilitated by efforts to promote health via information provision and educational strategies. I propose that perceived responsibility plays a role in mediating the tendency to moralise about health and behaviour. Since I argue that states ought to avoid direct and indirect moralisation of people's health-related behaviour, this suggests states must be cautious with regard to the use of responsibility-indicating interventions (including informational and educational campaigns) to promote health.

Tobacco-attributable burden of cancer according to socioeconomic position in France

Smoking is a major preventable cause of cancers and is increasingly concentrated among the most deprived individuals leading to increasing socioeconomic inequalities in the incidence of cancers linked to smoking. We aimed to estimate the tobacco-attributable cancer burden according to socioeconomic position in France. The analysis was restricted to cancer sites for which tobacco smoking was recognized as a risk factor. Cancer cases by sex, age group and European Deprivation Index (EDI) among people aged 30-74 between 2006 and 2009 were obtained from cancer registries covering ∼20% of the French population. The tobacco-attributable burden of cancer according to EDI was estimated applying the population attributable fraction (PAF) computed with the Peto-Lopez method. The PAF increased from 56% in the least deprived EDI quintile to 70% in the most deprived EDI quintile among men and from 26% to 38% among women. In total, 28% of the excess cancer cases in the four most deprived EDI quintiles in men and 43% in women could be prevented if smoking in these 4 EDI quintiles was similar to that of the least deprived EDI quintile. A substantial smoking-attributable burden of cancer by socioeconomic position was observed in France. The results highlight the need for policies reducing tobacco consumption. More comprehensive interventions integrating the various dimensions of health determinants and proportionate according to socioeconomic position may essentially contribute to the reduction of socioeconomic inequalities in cancer.

Smoking on the margins: a comprehensive analysis of a municipal outdoor smoke-free policy

BACKGROUND

This study examined the formulation, adoption, and implementation of a ban on smoking in the parks and beaches in Vancouver, Canada.

METHODS

Informed by Critical Multiplism, we explored the policy adoption process, support for and compliance with a local bylaw prohibiting smoking in parks and on beaches, experiences with enforcement, and potential health equity issues through a series of qualitative and quantitative studies.

RESULTS

Findings suggest that there was unanimous support for the introduction of the bylaw among policy makers, as well as a high degree of positive public support. We observed that smoking initially declined following the ban's implementation, but that smoking practices vary in parks by location. We also found evidence of different levels of enforcement and compliance between settings, and between different populations of park and beach users.

CONCLUSIONS

Overall success with the implementation of the bylaw is tempered by potential increases in health inequities because of variable enforcement of the ban; greatest levels of smoking appear to continue to occur in the least advantaged areas of the city. Jurisdictions developing such policies need to consider how to allocate sufficient resources to enhance voluntary compliance and ensure that such bylaws do not contribute to health inequities.

Quantifying the mediating effects of smoking and occupational exposures in the relation between education and lung cancer: the ICARE study

Smoking only partly explains the higher lung cancer incidence observed among socially deprived people. Occupational exposures may account for part of these inequalities, but this issue has been little investigated. We investigated the extent to which smoking and occupational exposures to asbestos, silica and diesel motor exhaust mediated the association between education and lung cancer incidence in men. We analyzed data from a large French population-based case-control study (1976 lung cancers, 2648 controls). Detailed information on lifelong tobacco consumption and occupational exposures to various carcinogens was collected. We conducted inverse probability-weighted marginal structural models. A strong association was observed between education and lung cancer. The indirect effect through smoking varied by educational level, with the strongest indirect effect observed for those with the lowest education (OR = 1.34 (1.14-1.57)). The indirect effect through occupational exposures was substantial among men with primary (OR = 1.22 (1.15-1.30) for asbestos and silica) or vocational secondary education (OR = 1.18 (1.12-1.25)). The contribution of smoking to educational differences in lung cancer incidence ranged from 22 % (10-34) for men with primary education to 31 % (-3 to 84) for men with a high school degree. The contribution of occupational exposures to asbestos and silica ranged from 15 % (10-20) for men with a high school degree to 20 % (13-28) for men with vocational secondary education. Our results highlight the urgent need for public health policies that aim at decreasing exposure to carcinogens at work, in addition to tobacco control policies, if we want to reduce socioeconomic inequalities in the cancer field.

Lifestyle Vaccines and Public Health: Exploring Policy Options for a Vaccine to Stop Smoking

Experimental vaccines are being developed for the treatment of 'unhealthy lifestyles' and associated chronic illnesses. Policymakers and other stakeholders will have to deal with the ethical issues that this innovation path raises: are there morally justified reasons to integrate these innovative biotechnologies in future health policies? Should public money be invested in further research? Focusing on the case of an experimental nicotine vaccine, this article explores the ethical aspects of 'lifestyle vaccines' for public health. Based on findings from a qualitative study into a vaccine for smoking cessation, the article articulates possible value conflicts related to nicotine vaccination as an intervention in tobacco control. The 'vaccinization' of lifestyle disease piggybacks on the achievements of classic vaccines. Contrary to expectations of simplicity and success, quitting smoking with a vaccine requires a complex supportive network. Social justice and public trust may become important ethical challenges when deciding whether to use further public funds for research or whether to implement these innovative vaccines in the future.

Personalised Medicine and Scarce Resources: A Discussion of Ethical Chances and Challenges from the Perspective of the Capability Approach

In the aftermath of the economic crisis that started in 2008, resources have become scarcer than ever in some countries, also in health care. Priority setting and rationalisation of existing resources also affect pharmaceutical innovations, including those that would contribute to what is called personalised medicine. In this paper, we will highlight the ethical issues surrounding rationalisation and its impact on personalised medicine through the lens of the capability approach. Thereby, challenges to and opportunities for personalised medicine will be examined, assessing how they affect patients' 'real options' to access innovative therapies. In our focus on the 'first challenge: citizens and patients' of the so-called Strategic Research and Innovation Agenda, the strength of the capability approach becomes particularly apparent in identifying what different values are at stake in this context.

The Economic Crisis and Its Ethical Relevance for Public Health in Europe - an Analysis in the Perspective of the Capability Approach

Policy responses to the economic crisis have manifest consequences to European population health and health systems. The aim of this article is to assess, by using the capability approach advanced by Sen, the ethical dimension of trade-offs made in health policy due to austerity measures. From a capability approach point of view, austerity measures such as reducing resources for health care, further deregulating the health care market or moving towards privatisation are ethically challenging since they limit opportunities and capabilities for individuals of a population. Public policies should thus aim to guarantee sufficient capabilities (options to access health care and possibilities to make healthy choices) for its populations. Prioritising those in need is a notion the capability approach particularly focuses on in its goal of supporting those with the least capabilities.

[Public health program planning through the capabilities lens]

As a theory of distributive justice, Amartya Sen's theory of capabilities questions the choices and decisions associated with the development and planning of public health programs. In this paper, the authors describe Sen's approach and explore its implications for public health by applying it to the case of tobacco control programs. Based on the tobacco control objectives set by the WHO and on the MPOWER package of measures, they notice that the translation of the objectives in capabilities call for a greater attention to the conditions of living of the different population groups. It also put into doubt the measures restricting access to tobacco products that do not account for their differing impacts on adults. The authors conclude that this ethical perspective is likely to be controversial as it may rank freedom as a value that overrides health.