Reenergizing public health through precaution

Cigarettes butt littering: The story of the world's most littered item from the perspective of pollution, remedial actions, and policy measures

Cigarettes butt (CB) is one of the most littered items on the planet. This paper critically analyzes the factors responsible for CB littering, and associated environmental ramifications, and reviews all the possible technical, behavioural, and policy-based solutions. Even while smoking has declined globally, middle-income nations have seen an increase in consumption, which may be related to increased affordability and a lack of public awareness. The smokers' individual beliefs and habits, environmental ignorance, covert littering as a result of social taboos associated with smoking, and behavioural gaps between intention and action might all be contributing factors to CBs' littering behaviour. The low biodegradability of cellulose acetate filters and toxic chemical leaching from CBs are the most important aspects of CB environmental toxicity. The small size and low economic value of CB contribute to the inefficiencies of current waste collection and management systems. The current research on CB valorisation includes fired-clay bricks, asphalt concrete, biofilms, sound absorber, cellulose pulp, pesticides, and insecticides as downstream mitigation strategies. This study highlights the urgent need for policymakers to enforce regulations enabling innovative cigarette designs, the creation of deposit-refund schemes, extended producer responsibility and stringent waste collection mechanisms. Adopting gentler marketing strategies and non-confrontational behavioural nudges could result in an overall reduction in CB pollution.

The Influence of Public Health Faculty on College and University Plans During the COVID-19 Pandemic

The purpose of this study was to explore whether the institutional presence of public health expertise within colleges and universities was associated with operational plans for the fall semester of 2020. Using cross-sectional data collected by the College Crisis Initiative of Davidson College, six levels of instructional modalities (ranked from least to most restrictive) were compared between Council on Education of Public Health (CEPH)-accredited and non-CEPH-accredited 4-year institutions. Institutions with CEPH-accredited schools and programs were more likely to select some restrictive teaching modalities: 63.8% more likely to use hybrid/hyflex or more restrictive and 66.9% more likely to be primarily online (with some in person) or more restrictive. However, having CEPH-accredited programs did not push institutions to the most restrictive modalities. COVID-19 cases in county, enrollment, and political affiliation of the state governor were also found to be associated with instructional modality selection. While any ecological study has certain limitations, this study suggests that college and university fall plans may have been influenced by the presence of CEPH-accredited schools and programs of public health, and/or the input of their faculty. The influence of relevant faculty expertise on institutional decision-making can help inform college and university responses to future crises.

The Misuse of the Precautionary Principle in Justifying Australia's Ban on the Sale of Nicotine Vaping Products

In Australia, the precautionary principle has been used to justify an effective sales ban on nicotine vaping products (NVPs) by requiring all NVPs to be approved as medicines. Australia's policy is out of step with other English-speaking countries, which allow the sale of NVPs as consumer products. We provide a brief history of the precautionary principle, discuss guidelines on how it should be used, and examine key documents from Australian policy debates to describe how the precautionary principle has been misapplied in justifying Australian NVP policy. We argue that the precautionary principle has been inappropriately applied to NVP regulation in Australia in that it has: failed to consider the regulation of similar products, imposed regulations that are disproportionate to the level of risk, failed to assess the costs of its regulatory approach, and failed to undertake a cost/benefit analysis of a range of available regulatory options. Australian policy illustrates the risks of regulating nicotine products in isolation rather than considering NVPs as falling on a continuum of harmful nicotine products. Implications: The precautionary principle has been misapplied to NVP regulation in Australia. We recommend that the precautionary principle be used in a way that regulates nicotine products in proportion to their risks.

Endocrine Disruptors and the Induction of Insulin Resistance

INTRODUCTION

The incidence of insulin resistance syndrome and type 2 diabetes mellitus has increased at an alarming rate worldwide and constitutes a serious challenge to public health care in the 21st century. Endocrine disrupting chemicals are defined as "substances or mixtures of substances that alter the endocrine system functions and, hence, adversely affect organisms, their progeny, or sub populations" and may be associated with this increase in prevalence.

OBJECTIVE

This study aimed to assess the role of endocrine disrupting chemicals in insulin resistance and the importance of approaching the subject during anamnesis.

METHODS

A full review of the literature regarding insulin resistance, type-2 diabetes and endocrine disruptors were conducted.

CONCLUSION

Large-scale production and distribution of endocrine disrupting chemicals coincide with the increase in the prevalence of insulin resistance globally. In recent years, studies have shown that endocrine disrupting chemicals are positively associated with insulin resistance syndrome, evidenced by worse prognoses among individuals with higher levels of exposure. Health professionals should recognize the forms of exposure, most susceptible people, and lifestyle habits that can worsen patients' prognoses.

Study design, size, and adequate exposure data as the crucial aspects in cancer risk assessment and implementation of the precautionary principle

Traditional approaches and study design in cancer epidemiology have not been very successful in identifying and evaluating adequately the potential risk and/or protective factors associated with the disease. The main reasons for the failure are often due the small study sample size, and inadequate exposure information. In this paper, issues and approaches relevant to these two challenges are discussed. Multicentre study is proposed as a way to increase study size and to mitigate criticism about meta-analysis of independent studies. A multicentre study of large cohort or case-control studies also offer an exciting opportunity to study the contribution of epigenetic events that may be associated with lifestyle and environmental risk factors for human health. Optimizing methods for exposure assessment and how to reduce exposure to misclassification represent a difficult component in epidemiological studies. A potentially useful approach for improving exposure estimation is to rely on biomarkers of exposures. An example is provided to demonstrate how biomarkers of exposures could provide valuable information in addition to exposure measurements in traditional epidemiological studies. Finally, it is argued that risk assessment and the precautionary principle should not be viewed as conflicting paradigms but, rather, as a complementary approach for developing appropriate policies to address risks posed by exposure to carcinogens and a wide spectrum of other health hazards.

Deploying the Precautionary Principle to Protect Vulnerable Populations in Canadian Post-Market Drug Surveillance

Drug regulatory bodies aim to ensure that patients have access to safe and effective drugs; however, no matter the quality of pre-licensure studies, uncertainty will remain regarding the safety and effectiveness of newly approved drugs until a large and diverse population uses those drugs. Recent analyses of Canada’s post-market drug surveillance (PMDS) system have found that Canada’s PMDS system requires strengthening and that efforts must be improved to monitor and address the safety and effectiveness of approved drugs among vulnerable populations. Given the uncertainty that exists when drugs enter the market, some have suggested that the precautionary principle is relevant to guiding decision-making in this context. This paper responds to recommendations that the Canadian PMDS system should be responsive to the health needs of vulnerable populations by assessing the utility of deploying the precautionary principle to guide a post-market strategy for vulnerable populations.

One Health and Zoonotic Uncertainty in Singapore and Australia: Examining Different Regimes of Precaution in Outbreak Decision-Making

A One Health approach holds great promise for attenuating the risk and burdens of emerging infectious diseases (EIDs) in both human and animal populations. Because the course and costs of EID outbreaks are difficult to predict, One Health policies must deal with scientific uncertainty, whilst addressing the political, economic and ethical dimensions of communication and intervention strategies. Drawing on the outcomes of parallel Delphi surveys conducted with policymakers in Singapore and Australia, we explore the normative dimensions of two different precautionary approaches to EID decision-making—which we call regimes of risk management and organizing uncertainty, respectively. The imperative to act cautiously can be seen as either an epistemic rule or as a decision rule, which has implications for how EID uncertainty is managed. The normative features of each regime, and their implications for One Health approaches to infectious disease risks and outbreaks, are described. As One Health attempts to move upstream to prevent rather than react to emergence of EIDs in humans, we show how the approaches to uncertainty, taken by experts and decision-makers, and their choices about the content and quality of evidence, have implications for who pays the price of precaution, and, thereby, social and global justice.

Decision-making in livestock biosecurity practices amidst environmental and social uncertainty: Evidence from an experimental game

Livestock industries are vulnerable to disease threats, which can cost billions of dollars and have substantial negative social ramifications. Losses are mitigated through increased use of disease-related biosecurity practices, making increased biosecurity an industry goal. Currently, there is no industry-wide standard for sharing information about disease incidence or on-site biosecurity strategies, resulting in uncertainty regarding disease prevalence and biosecurity strategies employed by industry stakeholders. Using an experimental simulation game, with primarily student participants, we examined willingness to invest in biosecurity when confronted with disease outbreak scenarios. We varied the scenarios by changing the information provided about 1) disease incidence and 2) biosecurity strategy or response by production facilities to the threat of disease. Here we show that willingness to invest in biosecurity increases with increased information about disease incidence, but decreases with increased information about biosecurity practices used by nearby facilities. Thus, the type or context of the uncertainty confronting the decision maker may be a major factor influencing behavior. Our findings suggest that policies and practices that encourage greater sharing of disease incidence information should have the greatest benefit for protecting herd health.

The Precautionary Principle for Shift-Work Research and Decision-Making

Shift work (working outside of 6:00 AM to 6:00 PM) is a fixture of our 24-hour economy, with approximately 18 per cent of workers in the USA engaging in shift work, many overnight. Since shift work has been linked to an increased risk for an array of serious maladies, including cardiometabolic disorders and cancer, and is done disproportionately by the poor and by minorities, shift work is a highly prevalent economic and occupational health disparity. Here we draw primarily on the state of science around shift work and breast cancer to argue that shift work represents a public health threat serious enough to warrant a precautionary stance. We use the precautionary principle to advance our case and view it as a moral compass for shift work research, empowering public health to cast shift work within the domain of health disparities deserving action despite scientific uncertainty. With the precautionary principle, we call for a deliberative decision-making process and formation of a broad shift work research collaboration to protect the health of many millions who work at night.

Geoffrey Rose e o princípio da precaução: para construir a prevenção quaternária na prevenção

A prevenção tem sido medicalizada gerando danos iatrogênicos frequentes. Isso demanda prevenção quaternária (P4): evitar medicalização/intervencionismo desnecessários e danos iatrogênicos correlatos. Apresentamos, neste artigo, uma articulação conceitual orientadora da P4 na prevenção. Geoffrey Rose distinguiu entre medidas preventivas “redutivas” (reduzem riscos derivados da vida moderna, como sedentarismo e ultraprocessados na alimentação) e “aditivas” (adicionam fatores artificiais protetores, como vacinações, rastreamentos, fármacos hipolipemiantes). O grande potencial de danos das medidas preventivas aditivas exige aplicação sistemática do princípio da precaução. Este orienta que, havendo dúvidas científicas sobre danos potenciais significativos de uma atividade, o Estado deve ativamente evitá-los, por meio de atribuição do ônus da prova de eficácia/segurança da atividade aos proponentes, exploração de alternativas inofensivas e aumento da participação pública na decisão. Tal aplicação, crucial para a P4 na prevenção, amiúde não ocorre em práticas preventivas de alta prevalência e iatrogenia.

Safety of folic acid

There is a large body of literature demonstrating the efficacy of maternal folic acid intake in preventing birth defects, as well as investigations into potential adverse consequences of consuming folic acid above the upper intake level (UL). Recently, two authoritative bodies convened expert panels to assess risks from high intakes of folic acid: the U.S. National Toxicology Program and the UK Scientific Advisory Committee on Nutrition. Overall, the totality of the evidence examined by these panels, as well as studies published since the release of their reports, have not established risks for adverse consequences resulting from existing mandatory folic acid fortification programs that have been implemented in many countries. Current folic acid fortification programs have been shown to support public health in populations, and the exposure levels are informed by and adherent to the precautionary principle. Additional research is needed to assess the health effects of folic acid supplement use when the current upper limit for folic acid is exceeded.

Can Chemical Class Approaches Replace Chemical-by-Chemical Strategies? Lessons from Recent U.S. FDA Regulatory Action on Per- And Polyfluoroalkyl Substances

Concern about the toxicity and exposure of per- and polyfluoroalkyl substances (PFASs) is growing among scientists, regulators, and residents of contaminated communities. In 2016, the United States Food and Drug Administration (FDA) removed three food contact substances (FCSs) containing perfluorinated chemicals from the list of approved FCSs due to concerns regarding chemical safety. To investigate the significance and limitations of the FDA's regulatory action for environmental health research, advocacy, and regulation, we conducted a media analysis and qualitative interviews with a range of involved stakeholders. We find that the FDA's regulatory action represents a potential shift from chemical-by-chemical regulation toward class-based regulation, where groups of chemicals can be identified as sharing properties and risks, and are thus evaluated and regulated together. The FDA decision sets an important precedent of using a petition process to delist chemicals based on a safety standard. However, the narrow reach of this action also highlights the need for more comprehensive, precautionary chemical regulation capable of thoroughly evaluating classes of chemicals, and raises important questions about how classes of chemicals are delimited in environmental health science and regulation.

[Public health policies in Chile: seeking to regain trust]

Healthcare represents a key area in the public agenda. In the case of Chile, this central part of citizen demands has emerged with an increasing criticism of the health system, its actors and institutions, while a major democratic and legitimacy crisis in Chilean society unfolds. The starting point of this analysis is the link between the critical and widespread societal dissatisfaction with the legitimacy crisis in the health sector. There is an interdependence and parallelism between these two different aspects of the crisis. The analysis is built around the dimensions of trust and legitimacy as a potential driver of the conflict, taking as an analytical framework the socio-political matrix. Conceptual elements around the ideas of trust and legitimacy in public policies are reviewed. This article focuses on recent situations surrounding the dynamics of the Chilean health system such as the rise of the Instituciones de Salud Previsional (ISAPRE) and the market-driven health system, the failed health care reform of the last decade, conflicts of interest in the formulation of public policies, loss of legitimacy of healthcare authorities, and the role of the health professionals in this process. Finally, a discussion arises seeking to regain public trust as a central issue for the future development and sustainability of health policies.

Employing the Precautionary Principle to Evaluate the Use of E-Cigarettes

Electronic cigarettes (e-cigarettes) have emerged onto the public market as an alternative to tobacco cigarettes; however, science is inconclusive as e-cigarettes have not been thoroughly investigated, including their short- and long-term risks and benefits (1, 2). The question arises of whether e-cigarettes will become the future tobacco crisis. This paper connects the precautionary principle to the use of e-cigarettes in an effort to guide decision-makers in the prevention of adverse health outcomes and societal costs.

Tainted blood: Probing safety practices in the Danish blood system

The existing literature on donor screening in transfusion medicine tends to distinguish between social concerns about discrimination and medical concerns about safety. In this article, we argue that the bifurcation into social and medical concerns is problematic. We build our case on a qualitative study of the historical rise and current workings of safety practices in the Danish blood system. Here, we identify a strong focus on contamination in order to avoid ‘tainted blood’, at the expense of working with risks that could be avoided through enhanced blood monitoring practices. Of further significance to this focus are the social dynamics found at the heart of safety practices aimed at avoiding contamination. We argue that such dynamics need more attention, in order to achieve good health outcomes in transfusion medicine. Thus, we conclude that, to ensure continuously safe blood systems, we need to move beyond the bifurcation of the social and medical aspects of blood supply as two separate issues and approach social dynamics as key medical safety questions.

Advancing the science of environmental exposures during pregnancy and the gene-environment through the National Children's Study

In this article we provide nurses with information on the importance of studying environmental exposures during fetal, infant, and childhood development in the National Children's Study. Nurses should be aware of this study to aid in mitigating the complex health problems that arise from environment-health interactions. Nurses may help to educate the public, patients, and caregivers and are in an ideal position to be strong advocates for policy change and regulatory monitoring and enforcement.

Blood donation and institutional trust: risk, policy rhetoric, and the men who have sex with men lifetime deferral policy in Canada

This article examines the process of rebuilding institutional trust in the Canadian blood system in the aftermath of the tainted blood scandal. Our focus is the policy of lifetime deferral from donating blood for men who have sex with men. Drawing on findings from interviews with representatives of Health Canada's Expert Advisory Committee on Blood Regulation, the National Liaison Committee, Canadian Blood Services, and blood consumer groups, we demonstrate how claims making about rights, discrimination, science, and risk contribute to policy continuity. We also examine the link between policy continuity and the management of reputational risk.

Regulating the disposal of cigarette butts as toxic hazardous waste

The trillions of cigarette butts generated each year throughout the world pose a significant challenge for disposal regulations, primarily because there are millions of points of disposal, along with the necessity to segregate, collect and dispose of the butts in a safe manner, and cigarette butts are toxic, hazardous waste. There are some hazardous waste laws, such as those covering used tyres and automobile batteries, in which the retailer is responsible for the proper disposal of the waste, but most post-consumer waste disposal is the responsibility of the consumer. Concepts such as extended producer responsibility (EPR) are being used for some post-consumer waste to pass the responsibility and cost for recycling or disposal to the manufacturer of the product. In total, 32 states in the US have passed EPR laws covering auto switches, batteries, carpet, cell phones, electronics, fluorescent lighting, mercury thermostats, paint and pesticide containers, and these could be models for cigarette waste legislation. A broader concept of producer stewardship includes EPR, but adds the consumer and the retailer into the regulation. The State of Maine considered a comprehensive product stewardship law in 2010 that is a much better model than EPR. By using either EPR or the Maine model, the tobacco industry will be required to cover the cost of collecting and disposing of cigarette butt waste. Additional requirements included in the Maine model are needed for consumers and businesses to complete the network that will be necessary to maximise the segregation and collection of cigarette butts to protect the environment.

A Canadian framework for applying the precautionary principle to public health issues

The precautionary principle has influenced environmental and public health policy. It essentially states that complete evidence of a potential risk is not required before action is taken to mitigate the effects of the potential risk. The application of precaution to public health issues is not straightforward and could paradoxically cause harm to the public's health when applied inappropriately. To avoid this, we propose a framework for applying the precautionary principle to potential public health risks. The framework consists of ten guiding questions to help establish whether a proposed application of the precautionary principle on a public health matter is based on adequacy of the evidence of causation, severity of harm and acceptability of the precautionary measures.

A precautionary public health protection strategy for the possible risk of childhood leukaemia from exposure to power frequency magnetic fields

Background

Epidemiological evidence showing a consistent association between the risk of childhood leukaemia and exposure to power frequency magnetic fields has been accumulating. This debate considers the additional precautionary intervention needed to manage this risk, when it exceeds the protection afforded by the exposure guidelines as recommended by the International Commission on Non-Ionizing Radiation Protection.

Methods

The Bradford-Hill Criteria are guidelines for evaluating the scientific evidence that low frequency magnetic fields cause childhood leukaemia. The criteria are used for assessing the strength of scientific evidence and here have been applied to considering the strength of evidence that exposures to extremely low frequency magnetic fields may increase the risk of childhood leukaemia. The applicability of precaution is considered using the risk management framework outlined in a European Commission (EC) communication on the Precautionary Principle. That communication advises that measures should be proportionate, non-discriminatory, consistent with similar measures already taken, based on an examination of the benefits and costs of action and inaction, and subject to review in the light of new scientific findings.

Results

The main evidence for a risk is an epidemiological association observed in several studies and meta-analyses; however, the number of highly exposed children is small and the association could be due to a combination of selection bias, confounding and chance. Corroborating experimental evidence is limited insofar as there is no clear indication of harm at the field levels implicated; however, the aetiology of childhood leukaemia is poorly understood. Taking a precautionary approach suggests that low-cost intervention to reduce exposure is appropriate. This assumes that if the risk is real, its impact is likely to be small. It also recognises the consequential cost of any major intervention. The recommendation is controversial in that other interpretations of the data are possible, and low-cost intervention may not fully alleviate the risk.

Conclusions

The debate shows how the EC risk management framework can be used to apply the Precautionary Principle to small and uncertain public health risks. However, despite the need for evidence-based policy making, many of the decisions remain value driven and therefore subjective.

Learning the Lessons of the BSE Crisis

By any standard, the BSE crisis was a most difficult period in the public health of the UK. This period saw a previously unknown TSE emerge in cattle and then transmit to humans, a scenario which by August 2009 had cost 164 people their lives in the UK and which has resulted in an unknown number of other people incubating variant CJD (vCJD). The economic damage caused by this disease has been considerable. In April 2000, the government estimated that by the end of the 2001/2002 financial year, the total net cost of the BSE crisis to the Exchequer would be £3.7 billion (BSE Inquiry Report, Volume 10: 1). Less quantifiable consequences have also stemmed from this crisis. Chief amongst them has been significant damage to the public’s ability to trust the pronouncements of government on matters of food safety and risk. The scientific community has suffered inestimable damage to its expertise and to its capacity to provide objective, consistent scientific advice to the public. With such serious consequences emanating from the BSE affair, it is incumbent on all those who were involved in this tragic episode to reflect on the events that took place and to consider how things could have been done better. Such a reflective exercise has, of course, been conducted by Lord Phillips and his inquiry team who examined all the events that took place during the BSE epidemic and drew a wide-ranging set of lessons from these events. A reflective purpose is also a central motivation of the current chapter. However, the focus of this reflection – scientific reasoning in contexts of uncertainty – is altogether narrower than that undertaken during the public inquiry into BSE. Moreover, the question of reasoning in contexts of uncertainty was omitted from Lord Phillips’ inquiry into BSE and has also been overlooked within the vast literature that has been written on the topic of BSE both before and after this inquiry was conducted.

The ethical use of existing samples for genome research

Modern biobanking efforts consist of prospective collections of tissues linked to clinical data for patients who have given informed consent for the research use of their specimens and data, including their DNA. In such efforts, patient autonomy and privacy are well respected because of the prospective nature of the informed consent process. However, one of the richest sources of tissue for research continues to be the millions of archived samples collected by pathology departments during normal clinical care or for research purposes without specific consent for future research or genetic analysis. Because specific consent was not obtained a priori, issues related to individual privacy and autonomy are much more complicated. A framework for accessing these existing samples and related clinical data for research is presented. Archival tissues may be accessed only when there is a reasonable likelihood of generating beneficial and scientifically valid information. To minimize risks, databases containing information related to the tissue and to clinical data should be coded, no personally identifying phenotypic information should be included, and access should be restricted to bona fide researchers for legitimate research purposes. These precautions, if implemented appropriately, should ensure that the research use of archival tissue and data are no more than minimal risk. A waiver of the requirement for informed consent would then be justified if reconsent is shown to be impracticable. A waiver of consent should not be granted, however, if there is a significant risk to privacy, if the proposed research use is inconsistent with the original consent (where there is one), or if the potential harm from a privacy breach is considerable.

How Many Principles for Public Health Ethics?

General moral (ethical) principles play a prominent role in certain methods of moral reasoning and ethical decision-making in bioethics and public health. Examples include the principles of respect for autonomy, beneficence, nonmaleficence, and justice. Some accounts of ethics in public health have pointed to additional principles related to social and environmental concerns, such as the precautionary principle and principles of solidarity or social cohesion. This article provides an overview of principle-based methods of moral reasoning as they apply to public health ethics including a summary of advantages and disadvantages of methods of moral reasoning that rely upon general principles of moral reasoning. Drawing upon the literature on public health ethics, examples are provided of additional principles, obligations, and rules that may be useful for analyzing complex ethical issues in public health. A framework is outlined that takes into consideration the interplay of ethical principles and rules at individual, community, national, and global levels. Concepts such as the precautionary principle and solidarity are shown to be useful to public health ethics to the extent that they can be shown to provide worthwhile guidance and information above and beyond principles of beneficence, nonmaleficence, and justice, and the clusters of rules and maxims that are linked to these moral principles. Future directions likely to be productive include further work on areas of public health ethics such as public trust, community empowerment, the rights of individuals who are targeted (or not targeted) by public health interventions, individual and community resilience and wellbeing, and further clarification of principles, obligations, and rules in public health disciplines such as environmental science, prevention and control of chronic and infectious diseases, genomics, and global health.

O conceito de biossegurança à luz da ciência pós-normal: avanços e perspectivas para a saúde coletiva

Trata-se de um estudo de natureza teórico-conceitual, que analisa as limitações do conceito de biossegurança à luz da ciência pós-normal, buscando contribuir para o debate sobre as controvérsias associadas à biossegurança. Parte do pressuposto que a noção de biossegurança, ao basear-se em uma abordagem eminentemente tecnicista do risco, não responde de maneira satisfatória às questões que se apresentam. Sendo o principal propósito da biossegurança proteger a saúde e o meio ambiente, torna-se necessária uma mudança da perspectiva reducionista da ciência tradicional, na qual a noção de biossegurança foi concebida. Essa mudança deve ocorrer dentro de uma abordagem ampla, que destaque as noções de incerteza, complexidade e qualidade, assim como considerar a pluralidade de atores e interesses envolvidos nos complexos problemas ambientais e de saúde. Conclui-se que conceber a noção de biossegurança à luz da ciência pós-normal implica uma modificação fundamental, principalmente em relação à saúde coletiva: a substituição do discurso tecnicista onipotente por um diálogo entre os diversos atores sociais envolvidos nas questões ambientais e de saúde.

Children's environmental health and the precautionary principle

The concept of precaution has a long history in medicine and public health. The modern precautionary principle (PP), originating from environmental debates in Germany in the 1970s, has been included in many international agreements, such as the Treaty on European Union. PP is a public policy tool that justifies actions, which protect human health and the environment in face of uncertain risks. The outcome of the application of PP depends on the level, nature, and distribution of acceptable risks and on the availability of alternatives, and can range from taking no action to banning of substances or the activities of concern. Given the complex nature and uncertainty of environmental risks to children's health, a precautionary approach is warranted. Public health professionals and clinical practitioners could adopt such an approach within the wider context of considering the environment as a source of risks to children's health. Relevant knowledge and skills are needed to enable health care professionals to address these issues. New methodological and scientific approaches are necessary to make use of scattered, but potentially relevant clinical evidence in providing 'early warnings' of health hazards.

Pandemic threats and the need for new emergency public health legislation in Canada

The 2003 outbreak of Severe Acute Respiratory Syndrome (SARS) exposed serious limitations in Canada's ability to respond to a public health emergency. Considerable progress has been made since SARS in addressing these limitations, including the creation of the new Public Health Agency of Canada. A remaining contentious question is whether there is a need for new federal emergency public health powers. Approaches to public health problems are best handled through collaborative processes, recognizing the critical importance of the local public health response. Nevertheless, this paper argues that a legislative back-up plan must be available to the federal government in the event that collaborative relationships break down. At the minimum, legislation should give the federal government the authority to have guaranteed access to surveillance data during a public health emergency. The legislation should also consider providing the federal government with the authority to devote the nation's resources to the management of an emergency at its earliest stages. However, any legislative approach must be combined with the development of appropriate capacity at the national level to ensure that new powers can be adequately utilized and that required funding reaches public health officials at other levels of government.

Population level policy options for increasing the prevalence of smokefree homes

OBJECTIVE

To identify and evaluate the options for population level government policies to increase the prevalence of homes free of secondhand smoke.

METHODS

The literature was searched for population level policy options and evidence on them. Three criteria were used to evaluate the policy options: effectiveness, the reductions on inequalities in secondhand smoke exposure, and cost effectiveness. The setting was four developed, English speaking jurisdictions: Britain, USA, Australia, and New Zealand.

RESULTS

Evidence from all four countries shows some association between relatively comprehensive tobacco control programmes and lower prevalence levels of smoking in homes. The evidence of the effect of such programmes on inequalities in smokefree home prevalence is limited. No published evidence was found of the cost effectiveness of the programmes in achieving changes in smokefree homes. Within comprehensive programmes, there is some indirect evidence that some mass media campaigns could increase the prevalence of smokefree homes. Structural options that have potential to support smokefree homes include smokefree places legislation, and laws for the protection of children.

CONCLUSION

The available evidence to date suggests that comprehensive tobacco control programmes (to reduce the prevalence of smoking in the total population) are likely to be the most effective and sustainable option for increasing the prevalence of smokefree homes.

Application of the precautionary principle by senior policy officials: results of a Canadian survey

Though use of the controversial precautionary principle in risk management has increasingly been recommended as a guide for the construction of public policy in Canada and elsewhere, there are few data available characterizing its use in risk management by senior public policymakers. Using established survey methodology we sought to investigate the perceptions and terms of application of the precautionary principle in this important subset of individuals. A total of 240 surveys were sent out to seven departments or agencies in the Canadian government. The overall survey response rate was 26.6%, and our findings need to be interpreted in the context of possible responder bias. Of respondents, the overwhelming majority perceived the precautionary principle and the management of risk as complementary, and endorsed a role for the precautionary principle as a general guideline for all risk management decisions. However, 25% of respondents responded that the lack of clarity of the definition of the principle was a limitation to its effective use. The majority of respondents viewed their own level of understanding of the precautionary principle as moderate. Risk managers appeared to favor an interpretation of the precautionary principle that was based on the seriousness and irreversibility of the threat of damage, and did not endorse as strongly the need for cost effectiveness in the measures taken as a precaution against such threats. In contrast with its perceived role as a general guideline, the application of the precautionary principle by respondents was highly variable, with >60% of respondents reporting using the precautionary principle in one-quarter or less of all risk management decisions. Several factors influenced whether the precautionary principle was applied with the perceived seriousness of the threat being considered the most influential factor. The overwhelming majority of risk managers felt that "preponderance of evidence" was the level of evidence required for precautionary action to be instituted against a serious negative event. Overall, the majority of respondents viewed the precautionary principle as having a significant and positive impact on risk management decisions. Importantly, respondents endorsed a net result of more good than harm to society when the precautionary principle was applied to the management of risk.

La opacidad de los acuerdos generales de bienes y servicios en España

OBJECTIVE

To explore the intensity of the debate in the Spanish Parliament on the General Agreement on Trade in Services (GATS) developed by Spain and the World Trade Organization, and to compare it with the debate on the General Agreement on Tariffs and Trade (GATT).

METHODS

A systematic search and content analysis were performed of all parliamentary initiatives on GATS and GATT undertaken from 1979 to 2004 in the Spanish Parliament and Senate. The frequency and percentages of initiatives on both issues were calculated, and the final result and kinds of initiative were analyzed.

RESULTS

A total of 185 initiatives were presented in the Spanish Parliament on these agreements, of which 120 were on GATT, 8 were on GATS and 57 were on both agreements. Most of these initiatives were not discussed in parliament (GATT, 71%; GATS, 55.4%) or were the subject of political debate with low participation among parliamentary groups.

CONCLUSIONS

Despite the implications of the GATS for Spanish health policy, the agreement was developed with little prior political debate, which was even less intense than that on GATT. The parliamentary function of controlling the government should be reaffirmed in Spain.

The physical inactivity matrix: lessons from the classification of physical inactivity interventions

Physical inactivity (PI), a leading modifiable cause of disease and injury, is endemic in industrialised nations. Although considerable research has been undertaken in this field, we lack a system to synthesise the research literature to inform policy and identify research needs. The aims of this study were to (1) develop a system to classify physical inactivity intervention studies, (2) examine the distribution of PI interventions published in the peer-reviewed health literature using the system, and (3) consider implications for future research. We developed the Physical Inactivity Matrix (PIM), with 12 intervention points, created by the intersection of two dimensions: the intervention target (individual, physical environment and social/cultural environment) and the activity focus (transport, work/school, leisure and consumer). A formal search of the health research literature identified 529 eligible studies and each was classified into one of the 12 cells of the PIM. Most studies were categorised as: individual-leisure (68%), individual-work/school (12%) or social/cultural environment-leisure (13%). Only 4% targeted the physical environment. The findings of this initial application of the PIM support the call for greater investment in policies, interventions and research that focus on the relationship between the environment and PI, and transportation in particular. There would be merit in establishing the inter-rater reliability of the PIM and applying it to a wider variety of studies, including those published in the transportation and urban planning literatures. The PIM could be a useful tool for monitoring trends in research directions and funding levels over time and across countries.

Late lessons from early warnings: Toward realism and precaution with endocrine-disrupting substances

The histories of selected public and environmental hazards, from the first scientifically based early warnings about potential harm to the subsequent precautionary and preventive measures, have been reviewed by the European Environment Agency. This article relates the "late lessons" from these early warnings to the current debates on the application of the precautionary principle to the hazards posed by endocrine-disrupting substances (EDSs). Here, I summarize some of the definitional and interpretative issues that arise. These issues include the contingent nature of knowledge; the definitions of precaution, prevention, risk, uncertainty, and ignorance; the use of differential levels of proof; and the nature and main direction of the methodological and cultural biases within the environmental health sciences. It is argued that scientific methods need to reflect better the realities of multicausality, mixtures, timing of dose, and system dynamics, which characterize the exposures and impacts of EDSs. This improved science could provide a more robust basis for the wider and wise use of the precautionary principle in the assessment and management of the threats posed by EDSs. The evaluation of such scientific evidence requires assessments that also account for multicausal reality. Two of the often used, and sometimes misused, Bradford Hill "criteria," consistency and temporality, are critically reviewed in light of multicausality, thereby illustrating the need to review all of the criteria in light of 40 years of progress in science and policymaking.