Discuss Chronic Disease Prevention and Health Promotion
137© The Author(s) 2016 D.H. Barrett et al. (eds.), Public Health Ethics: Cases Spanning the Globe, Public Health Ethics Analysis 3, DOI 10.1007/978-3-319-23847-0_5
Chapter 5 Chronic Disease Prevention and Health Promotion
Chronic diseases include conditions such as heart disease, stroke, cancer, diabetes , respiratory conditions, and arthritis. In high-income countries, chronic diseases have long been the leading causes of death and disability. Globally, more than 70 % of deaths are due to chronic diseases, in the United States , more than 87 % (World Health Organization [WHO] 2011 ). Almost one in two Americans has at least one chronic condition (Wu and Green 2000 ). Aside from the cost in terms of human welfare, treatment of chronic disease accounts for an estimated three quarters of U.S. health care spending (Centers for Disease Control and Prevention [CDC] 2012 ). Chronic diseases directly affect overall health care budgets, employee pro- ductivity, and economies. Globally, noncommunicable diseases account for two- thirds of the overall disease burden in middle-income countries and are expected to rise to three-quarters by 2030, typically in parallel to economic development (World Bank 2011 ). Of particular concern to many low- and middle- income countries is that threats to population health occur on two fronts simultaneously: “In the slums of today’s megacities, we are seeing noncommunicable diseases caused by unhealthy diets and habits, side by side with undernutrition” (WHO 2002 ).
Four modifi able risk factors are principal contributors to chronic disease , associ- ated disability, and premature death: lack of physical activity, poor nutrition, tobacco use, and excessive alcohol consumption (CDC 2012 ). One in three adult Americans is overweight , another third is obese, and almost one-fi fth of young people between
The opinions , fi ndings , and conclusions of the author do not necessarily refl ect the offi cial position , views , or policies of the editors , the editors ’ host institutions , or the author ’ s host institution .
H. Schmidt , MA, PhD (*) Department of Medical Ethics & Health Policy, Center for Health Incentives and Behavioral Economics , University of Pennsylvania , Philadelphia , PA , USA e-mail: firstname.lastname@example.org
6 and 19 years of age is obese, even though rates are not increasing at previous lev- els (Katz 2013 ). Although smoking has declined considerably over recent decades, about 20 % of Americans still smoke . Rates of smoking are markedly different across socioeconomic groups, and much higher among economically disadvantaged people (Garrett et al. 2011 ). Globally, deaths from smoking are expected to increase dramatically in low-income countries. In the twentieth century, tobacco-use killed around 100 million people worldwide. In the twenty-fi rst century, an estimated one billion will die prematurely—a tenfold increase. By 2030, more than 80 % of deaths attributable to tobacco will be in low-income countries (WHO 2012 ).
In principle , if a risk factor can be modifi ed, then much illness and suffering (morbidity) and early death (mortality) can be avoided or prevented . Therefore, prevention and health promotion policies seek ways in which the impact of modifi – able risk factors can be reduced. How one analyzes the causal pathways that lead to the development of risk factors may encourage one to explore a range of different interventions. An obvious starting point is to focus on individual behavior or life- style , because what an individual does (or fails to do) typically plays a central role in chronic disease . Consider the following line of thought by John H. Knowles, an outspoken critic of the American health care system in the 1970s:
Prevention of disease means forsaking the bad habits which many people enjoy—[but the] cost of sloth, gluttony, alcoholic intemperance, reckless driving, sexual frenzy, and smoking is now a national, and not an individual, responsibility. This is justifi ed as individual free- dom —but one man’s freedom is another man’s shackle in taxes and insurance premiums. I believe the idea of a ‘right’ to health should be replaced by the idea of an individual moral obligation to preserve one’s own health—a public duty if you will. The individual then has the ‘right’ to expect help with information , accessible services of good quality , and minimal fi nancial barriers (Knowles 1977 ).
Knowles comment is interesting on several counts. First, it underscores that even though population health usually features centrally in health promotion , cost con- siderations are never far removed and are equally prominent in current debates, especially in political fora. 1
Second, in invoking three of the deadly sins (gluttony, sloth, and lust), Knowles illustrates in a frank way that discussions about health promotion are not confi ned to medical or public health concepts. Implicitly or explicitly, these discussions almost always entail moral concepts (such as personal responsibility or deserving- ness) that are embedded in deeply held normative frameworks.
1 For an example of such a political debate, see the 2012 platform of the U.S.’s Republican Party: “… approximately 80 % of health care costs are related to lifestyle —smoking, obesity, substance abuse —far greater emphasis has to be put upon personal responsibility for health maintenance …” (GOP 2012 ). Reforming Government to Serve the People is available at https://www.gop.com/ platform/ . This quote also illustrates the inaccurate use of statistics. Although the burden of chronic diseases is indeed roughly 80 %, it is an exaggeration to claim that personal responsibility alone accounts for the total burden. Exact estimates may not be straightforward due to complex interac- tions of different factors. Consequently, a more realistic estimate attributes 40 % to personal behavior, 30 % to genetic predispositions, 15 % to social circumstance, 10 % to inadequate health care, and 5 % to environmental causes (Schroeder 2007 ).
And fi nally—although Knowles acknowledges elsewhere in his essay the role of taxes and other measures to improve health and eradicate poverty—he concludes by stating “the costs of individual irresponsibility in health have now become prohibi- tive. The choice is individual responsibility or social failure ” (Knowles 1977 ). The policy interventions he mentions aim for broader recognition of personal responsi- bility and therefore focus on education and information campaigns to empower people to behave responsibly. But this analysis is shortsighted. It fails to consider the responsibility of those who produce, market, and sell products (e.g., unhealthy foods, drinks, or tobacco ) and of those who regulate markets or set business stan- dards (e.g., trade groups or national or regional policy makers). His point could best be made if all people lived in similar environments and conditions, had suffi cient disposable income, had ready access to healthy and affordable food, had equal opportunity to exercise, and experienced other health-conducive conditions. But this is not the case. People live in vastly different contexts, and many different fac- tors determine health (Fig. 5.1 ).
Although Fig. 5.1 provides a useful overview of many factors that affect health, the concept of “ lifestyle ,” commonly encountered in the broader debate around chronic diseases is problematic. It can suggest that people choose, for example, smoking or heavy drinking as others might decide between taking up golf or tennis as a hobby. The point is that “ lifestyle ” implies degrees of freedom and the possibil- ity of genuine opportunity and choice. But assume that you grew up in an inner-city
Fig. 5.1 Factors determining health and chronic diseases (Originally published in Dahlgren and Whitehead ( 1991 ). Reproduced from Acheson ( 1998 ). Reproduced with permission)
5 Chronic Disease Prevention and Health Promotion
borough as a child of low-income obese and smoking parents . Many in your family and social environment smoke and are obese. Compared to the national average, you are among the most overweight , and you fail to lose weight as an adolescent. You remain obese. Calling your obesity a matter of lifestyle makes little sense. Now assume you started smoking as a minor (<18 years of age) just as 88 % of U.S. adults who smoke daily (U.S. Department of Health and Human Services 2012 ). It can be cynical to treat this “ lifestyle ” as voluntary and freely chosen if, for example, many of your role models smoke and if smoking in your social setting and challeng- ing environment functions as a coping mechanism to relieve stress. The different spheres in the diagram therefore need to be understood as highly interdependent. Regarding terminology, the concept of lifestyle factors should be replaced with that of personal behavior . Doing so acknowledges that powerful constraints can severely infringe on the development of healthy habits and behavior. In the worst case, these constraints may thwart development of healthy habits and behaviors altogether, even when individuals have the best of intentions.Focusing on just the individual is therefore overly narrow when identifying poli- cies to prevent chronic diseases . Yet, removing the individual from the equation is also unhelpful (Schmidt 2009 ). The central ethical issues surrounding health pro- motion and prevention of chronic diseases concern the relative responsibilities of all agents whose actions infl uence the health of others. These agents include, in addi- tion to individuals, health workers, governments (at different levels), and corporate entities.5.2 IndividualsExcept for some genetic conditions and extremely toxic environments (i.e., chemi- cal exposure), individual behavior typically plays a causal role in bringing about bad—as well as good—health. People may or may not eat healthily; they may or may not use tobacco or illegal drugs; they may consume alcohol excessively or in moderation; they may exercise too little or too much; and they may regularly brush their teeth, go for medically recommended checkups, and take their medications — or fail to do so. However, it is important to recognize that implementation of mea- sures such as praise or blame, or fi nancial rewards, or penalties —although they presuppose a certain degree of causal responsibility—do not mean that individuals also automatically need to be held fully responsible in a moral (or legal) sense. Causal responsibility in the present context simply means that a person has behaved in ways that contributed to, say, poor health. Therefore, a smoker with lung disease arguably has some causal responsibility for the condition. But if it turns out that the smoker started becoming addicted as a child, it is clear that the outcome cannot simply be treated as the result of an entirely voluntary choice . Where there is no, or limited, opportunity of choice, there is the risk of “ victim blaming ” (Crawford 1977 ) and holding people responsible for factors that are, in fact, beyond theirH. Schmidt141control. Conversely, ignoring the scope of possible behavior change can lead to fatalism and resignation (Schmidt 2009 ).For individuals to take causal and other responsibility for their health, they require, among other things, information that they can understand, affordable access to health care, and, oftentimes far more important, environments conducive to health in which capabilities may be developed so that one can fl ourish in life (e.g., residen- tial, work, and play settings) (Venkatapuram 2011 ; Ruger 2006 ). According to the adage “ought implies can,” we can only hold people responsible for their actions if they could have acted otherwise. Of course, it is true in some sense that people who smoke , or overconsume unhealthy food, or fail to exercise, could oftentimes have acted otherwise, in principle : it was not literally impossible for them to act other- wise. However, the relevant question is not whether it is literally possible to engage in healthy behavior, but whether it reasonably feasible for people to engage in healthy behavior. Talk of personal responsibility therefore requires a clear focus on the settings in which people live and on their behaviors when presented with differ- ent choices. Consideration should also be given to the possibility that policies implementing personal responsibility through, for example, rewards and penalties , may impact core values underlying a health system, such as a sound doctor-patient relationship , equity , or risk sharing , which may affect their overall acceptability in positive or negative ways (Schmidt 2008 ).5.3 Formal and Informal Health WorkersHealth professionals play a central role in chronic disease prevention and health promotion (Dawson and Verweij 2007 ). In primary prevention , they focus on avert- ing poor health in the fi rst place and on promoting good health. In secondary pre- vention , they offer information , tests, and screenings aimed at early detection and treatment of diseases. Diabetes , blood pressure, and some cancer screenings can have utility, especially when targeting at-risk populations in a nonstigmatizing way. Primary care physicians are often in a good position to decide on the appropriate- ness of screenings. Their knowledge of patient background and overall situation can help them tailor tests on the supply side to the actual needs on the demand side, bearing in mind patient preferences and individual risks.Cost effectiveness aside, a physician would be wrong to offer every available test to every patient because the clinical benefi t is not always clear. A recent systematic review and meta-analysis of randomized controlled trials concerning general health checkups (i.e., comprising health risk assessments and biometric screening for high blood pressure, body mass index, cholesterol, and blood sugar) found no association with lower overall mortality or morbidity (Krogsbøll et al. 2012 ). On the basis of these fi ndings, the researchers caution that checkups may needlessly increase diag- noses and use of drugs. They recommend clinically motivated testing of individuals to initiate preventive efforts but discourage screening at the population-level for5 Chronic Disease Prevention and Health Promotion142lack of evidence. The authors acknowledge limitations in their research , including that most of the trials were relatively old and that changes in interventions and care pathways reduce applicability to current practice. All studies entailed voluntary invitations to get checkups , so selection bias may have overrepresented privileged people (in typically better health to start with) and not reached those needing atten- tion the most (Krogsbøll et al. 2012 ). The focus on all-cause mortality has also been criticized as setting too high a threshold (Sox 2013 ). Yet despite the somewhat intui- tive appeal of using general health checkups in secondary prevention , there is little robust evidence from randomized controlled trials to show any major impact on overall mortality.An ethical problem arises when offering preventive screenings that do not fol- low evidence-based guidelines (U.K. National Screening Committee 2013 ). Such screenings may increase the number of “worried well” who oftentimes are con- fused by complex probabilities of detecting and preventing diseases . Clinicians must therefore do their utmost to understand risks and benefi ts of screening tests and communicate these to patients in ways that are easily comprehensible and not misleading (Wegwarth and Gigerenzer 2011 ). For example, a physician might tell his 50-year-old patient that she should undergo breast cancer screening because it reduces risk by 14 %. But this information is incomplete, as relative risk rates alone obscure the basic reference point against which the comparison is made. Another way of providing the same information would be to use absolute risk rates and to say that if one screens 1000 women for 20 years, four breast cancer deaths can be averted, even though eight among all screened women still die from breast cancer. In addition, over the 20 years, the 1000 women taking part in screening experience 412 false positives, and of 73 women who are diagnosed with breast cancer, 19 experience overdetection and are treated for a cancer that would not have developed into a lethal tumor, with treatment typically consisting of hormone- radio- or chemo- therapy, and partial or full surgical breast-removal (Hersch et al. 2015 ). This way of presenting data (Fig. 5.2 ), especially when com- bined with other relevant information about screening accuracy and rates of over- diagnoses, provides more adequate context for considering benefi ts and risks—yet, this presentation method is far from being universally adopted (Gigerenzer et al. 2010 ).Adequate risk information in secondary prevention matters not only from a patient-empowerment perspective but also because it can mitigate real or perceived confl icts of interests of physicians. Physicians, anyone who markets or manufac- tures screening equipment, and those who analyze data typically experience fi nan- cial gain when more patients undergo screening . Therefore, a central ethical issue of secondary prevention is not only how to avoid premature mortality in the most effi - cient and cost effective way but also how to eliminate potential confl icts of inter- ests. Patients can become entangled in competing interests, as illustrated by the controversy surrounding prostate-specifi c antigen, or PSA, testing to detect prostate cancer. Although physicians and others experienced fi nancial gain, patients experi- enced no reduced mortality and instead higher morbidity and loss of quality of lifeH. Schmidt143due to the entailed procedures (Ablin 2010 ). The question of “what is the magnitude of benefi ts and risks , and to whom?” is therefore an important one to ask in all sec- ondary prevention , especially because the net gain for patients is not always obvious.For these and other reasons, many in the public health community are skeptical about the relative utility of secondary prevention in a clinical context. Often this is paired with a call for shifting political and fi nancial support to primary prevention and the broader sphere of public health (Sackett 2002 ; Mühlhauser 2007 ). Here, the objective is to avoid poor health in the fi rst place by empowering people with differ- ent ways to lead healthy lives. Too often, only the privileged few in certain popula- tions have this capability (WHO 2008 ).Of course, this way of thinking immediately broadens the concept of health pro- fessional . Clearly, it is outside the scope of, say, a hospital-based general internist to reduce junk-food outlets or to increase exercise opportunities in a low-income part of town, even if the internist has good reasons to believe these structural features are key contributors toward rising levels of obesity among patients. But once we recog- nize how differences among settings in which people live can affect the incidence and prevention of chronic diseases, it becomes apparent that public health profes- sionals outside the clinical context have as much, if not more, of a role to play compared to physicians when it comes to chronic disease prevention and health promotion.A range of corresponding interventions are relevant to this discussion, including literacy, safe sex, hygiene and health awareness campaigns, fi nancial subsidies for healthy food or gyms, exercise stations in parks, breastfeeding rooms in workplaces,Relative risk data can be misleading or confusing. Absolute risk data can provide more appropriate information and minimize possible conflicts of interest. Visual illustrations similar to the ones shown below are helpful as part of evidence-based mammography screening decision-aids.Fig. 5.2 Communicating benefi ts and harms of breast screening (Originally published in Hersch et al. ( 2015 ). Used with permission)5 Chronic Disease Prevention and Health Promotion144and fl uoridation of water. The public health fi eld is heterogeneous and comprises numerous different actors both in and outside a clinical context. Public health, despite its many contexts and support from government and private sectors, is typi- cally underfunded. This is especially true for informal grassroots campaigns, which often have a considerable competitive advantage over formal program structures. Grassroots campaigns evolve from the communities they seek to help. Because nearly every intervention that addresses chronic diseases has to do with how one lives one’s life, top-down interventions are often experienced as intrusive forms of external meddling (Morain and Mello 2013 ). Conversely, initiatives led by a com- munity member can be perceived more sympathetically than instructions from men in white coats who speak in formal and technical terms (unless, of course, that hap- pens to be the target population , which, typically, it is not).Health professionals working on chronic disease prevention and health promo- tion therefore span a wide fi eld. In a looser sense, many professionals not generally seen as concerned with health could be included too, such as teachers, architects, town planners , or spiritual leaders. Each has perspectives that can be highly infl uen- tial, but each is inherently limited in scope because chronic conditions result from complex interplay of different factors. This raises another key ethical issue involv- ing how to determine the optimal mix of strategic approaches, bearing in mind the relative strengths and weaknesses.Further, just as users and payers of health care should have a keen interest in hav- ing systematic studies and evaluations done to determine which of several drugs aimed at reducing, for example, severe headache, is most effi cacious (and cost effective), we should be interested in the evidence base for possible benefi ts and harms of different interventions being implemented by health professionals con- cerned with chronic conditions. Yet, in an almost tautologic approach, health profes- sionals often assume any preventive method will be good because its aim is prevention. But several strategies could be aimed at the same problem. Given that budgets are generally limited, it can be useful to determine which intervention is most effective and, for example, how its relative effectiveness and cost compare with its intrusion into peoples’ lives. Such comparisons can help achieve value for money, even if the complex interplay of agents complicate this process.5.4 Governments (At Different Levels)Chronic disease prevention and health promotion policies often face criticism for promoting a “ nanny state .” This means that although government may legitimately use taxes and other measures to create health-conducive infrastructure that pre- vents chronic disease such as clean water supplies, sanitation services, or clean air acts, it should otherwise stay out of people’s lives, and, in particular, refrain from telling citizens how to live their life (Childress et al. 2002 ; Gostin 2010 ; DawsonH. Schmidt145and Verweij 2007 ). Many good reasons support this viewpoint. Still, many vari- ables related to chronic diseases are linked to legitimizing governments in the fi rst place.For example, consider the U.S. Declaration of Independence. It declares that “all men are created equal; that they are endowed by their Creator with certain unalienable Rights; and that among these are Life, Liberty , and the pursuit of Happiness.” Numerous countries express similar sentiments in legal frameworks and charge states with providing environments that enable conditions for a good life, and prevent harm . Moreover, building on the United Nations’ (U.N.) International Covenant on Economic , Social and Cultural Rights of 1966 and clarifying General Comment 14 by the U.N.’s Committee on Economic, Social and Cultural Rights, several countries have incorporated the right to health in their constitutions (WHO 2013 ). Yet, not all people live equally long, nor are they equally happy (in a nontrivial sense). For example, life expectancy differs widely, not just between countries at different levels of development, but also within countries, and sometimes with differences of almost 30 years across just 10 miles (see the data on two areas in Glasgow, Scotland, located near one another, Fig. 5.3 ). Chronic diseases are a major contributor to this variation.Going back to the focus on personal responsibility , one might argue this variation in life expectancy is due to some people simply not wanting to be healthy or living long. But this is clearly myopic. Government planning at different levels has immense impact on both the prevalence and prevention of chronic diseases. It is sometimes argued that the best prevention is to instill in people the desire to live long and healthily (Rosenbrock 2013 ). For some, this might entail a state- guaranteed minimum income (irrespective of whether one works), since economic livelihood isFig. 5.3 Male life expectancy, between- and within-country inequities, selected countries (Figure is adapted from World Health Organization ( 2008 ))5 Chronic Disease Prevention and Health Promotion146of course a major factor in how one views one’s own future. While a positive impact of such policies on the incidence of chronic disease and mortality would certainly be plausible, there is a wide range of less radical and politically more feasible options in the menu of different levels of government action. These include town planning, zoning laws , school and university meal plans, and, of paramount impor- tance, regulation of industry where markets fail. These and other interventions can only be implemented by governments. An important part of chronic disease preven- tion and health promotion is to monitor where differences in morbidity and mortal- ity are such that government action is warranted, and to impress on elected offi cials their responsibility in creating appropriate environments.The monolithic notion of “the” government is, of course, an overly simplistic one. Key personnel in health departments may well wish to limit the size of, for example, soft drinks. Or they may wish to standardize ways in which nutritional content is shown on food packaging. Such measures would enable more informed consumer choice, and, more indirectly, incentivize producers to reconsider whether food composition can be optimized for health impact, given the second- ary “showcasing” effect of labeling. 2 But their colleagues in trade or industry, as well as in the treasury, may point out the risk of tax shortfalls that could result from lower consumption. Or they may worry about pushback from lobbyists in the corporate sector who fear losing profi ts for their clients . Politicians may often be more concerned with their short-term re-election prospects than with making substantial (or even just incremental) longer-term progress on chronic disease prevention. These confl icting perspectives within government are inevitable . But only government can determine the playing fi eld and ground rules for industries producing, selling and marketing food, drink, tobacco , and other products contrib- uting to unhealthy behavior. In liberal economies that, typically, pursue a hands- off approach toward regulating markets, the central ethical challenge then is to decide at which points markets are considered to have failed, other options of market regulations are unfeasible, and government action is warranted, despite possible drawbacks.A second closely related question is what intervention to pursue once the need for action has been identifi ed. Figure 5.4 shows the Intervention Ladder published in a report by the Nuffi eld Council on Bioethics ( 2007 ) on public health ethics. The model suggests that governments have a range of different options at their disposal that become increasingly intrusive or paternalistic the higher one moves up the lad- der. At the same time, each rung up the ladder requires more robust justifi cation and evidence , although the report points out the bottom rung, “doing nothing or simply monitoring,” also requires justifi cation.2 For example, it has been shown that large U.S. chain restaurants changed menus in anticipation of a legal mandate requiring public calorie posting, resulting in a 12 % reduction in calories (or about 56 fewer calories per item, see Bleich et al. 2015 ).H. Schmidt1475.5 Corporate EntitiesIn the United States , the Institute of Medicine ( 1988 ) defi nes public health as “what we, as a society, do collectively to assure the conditions in which people can be healthy.” In the United Kingdom , the Faculty of Public Health ( 2010 ) of the Royal Colleges of Physicians suggests that public health is the “science and art of prevent- ing disease , prolonging life, and promoting health through organized efforts of soci- ety.” These, and other conceptualizations, emphasize the collective nature of public health work (Verweij and Dawson 2007 ). Companies that facilitate consumer access to tobacco or to healthy and unhealthy food and drink are part of society and con- tribute via goods, services, and employment opportunities. In return, they often receive generous tax breaks. Company operations benefi t further from diverse fi nan- cial arrangements and infrastructures put in place by governments to ensure stability• Eliminate choice: Prohibit substances such as transfats. Remove obese childrenfrom their home.• Restrict choice: Ban unhealthy foods from shops or restaurants. Add fluoride to water.• Guide choice through disincentives: Tax cigarettes. Discourage the use of carsin inner cities through charging schemes or by limiting parking spaces.• Guide choice through incentives: Give tax breaks to commuters.• Guide choice by changing the default policy: In restaurants, instead ofproviding fewer health options and including fries as a standard side dish (withhealthier options available) make healthy options standard menu fare (with friesoptional). Regulate salt levels of fast food meals because consumers can add saltafterwards.• Enable choice: Create tax-funded smoking cessation programs, build cycle lanes,or provide free fruit in schools.• Provide information: Implement campaigns to encourage people to walk moreor to eat certain amounts of fruit and vegetables daily.• Do nothing or simply monitor the current situation.In preventing chronic diseases and promoting health, governments have a range ofpolicy options differing in justification, evidence requirements, and extent ofintrusion.Fig. 5.4 The intervention ladder (Adapted from Nuffi eld Council on Bioethics ( 2007 ))5 Chronic Disease Prevention and Health Promotion148of civic and economic life, since both are essential to how markets function. It is therefore reasonable to ascribe some responsibilities for public health to companies. In many instances, this is achieved through voluntary corporate social commit- ments, such as charters or formal partnerships with charitable or community orga- nizations. Increasingly, companies view their own ethical actions as an attractive side of their branding, especially in countries where consumers’ awareness is high.Although many companies generate profi ts through healthful products, many others benefi t from bringing products to market that will likely cause harm . Product demand is rarely a function of basic human needs but, rather, is defi ned by social and cultural norms . These norms are often fueled—if not generated—by aggressive marketing to adults and children . The basic tension regarding the role of companies in relation to public health is their prima facie obligation to contribute to population health , while also maximizing owners or shareholders’ profi ts. Public health would be promoted by measures such as providing honest nutritional information and other content of products; avoiding claims that are misleading (as is sometimes the case with vitamins, supplements, or some diagnostic tests); not denying or under- playing potential harm (as with so-called alcopops, which are high-alcohol drinks made to look like soft drinks); or not exploiting the “pester power ” of children , particularly by marketing products to them and confusing the boundary between giving information and advertising . But realizing these aspirations typically curbs consumption and therefore reduces market shares and profi ts.Companies therefore prefer as little regulation as possible and favor information- based over price-based interventions or more intrusive options (Fig. 5.4 ). In all high-income countries, company and government offi cials liaise to negotiate con- sumer protection policies , insofar as political and consumer pressure creates demand. These negotiations often reveal the limitations of corporate social respon- sibility , as perhaps illustrated most clearly by the tobacco industry. For decades, the industry pursued the strategy that there was no hard evidence that tobacco was harmful to health. When this strategy became too absurd to sustain, and, in particu- lar, when the evidence of the harmful effects of secondary smoke became over- whelming, the industry caved in and agreed to implement a series of consumer protection measures in most developed countries (Brandt 2007 ). However, in many instances, this tug-of-war was repeated in other countries, despite a range of robust provisions in WHO’s Framework Convention on Tobacco Control ( 2003 ), the only supranational hard law instrument on a major risk factor for chronic conditions that is legally binding in more than 170 countries. From a narrow business perspective, this behavior is entirely rational. But from an ethical viewpoint, it is extremely ques- tionable. For example, it has been accepted in the United States and Europe that it is not appropriate to glorify tobacco on billboards, to give cigarettes away for free in promotions at rock concerts geared towards young people, or to sell them indi- vidually, then why should these and other practices be commonplace in many low- income countries, especially in Africa (Action on Smoking and Health 2007 )? The obscene tenfold global increase in deaths attributable to tobacco in the twenty-fi rst century has already been noted. What makes this prospect all the more appalling is the industry’s refusal to take seriously the standards it agreed to uphold in high-H. Schmidt149income countries. For if these standards were upheld, history would not repeat itself with such horrifi c consequences.5.6 Case StudiesIn the following fi ve cases, the reader is put in the position of a public health prac- titioner to illustrate how key ethical issues can arise in the prevention of chronic diseases and health promotion. The cases highlight several real-world, practical constraints : limited budgets; insuffi cient evidence for how interventions will work in structurally different settings; organizational constraints, particularly from spe- cifi c formats for decision making; and clashes of perspectives and worldviews. Three cases concern children , an especially vulnerable population (Verweij and Dawson 2011 ). The cases ask whether the parents alone can make sound health decisions for their children, and if not, what interventions would be acceptable to reach the parents. The interventions range from chemical and behavioral to social ones, and central to each are ethical questions around their justifi cation (because of competing interests) and oftentimes unclear evidence. Several cases touch on whether or not to engage the public in decision making—and if so, how? Public engagement is an increasingly popular approach being applied broadly to health policy . Yet, it is not always clear who should be involved in which decision-making processes and on what grounds (Kreis and Schmidt 2013 ).Mah et al. provide an intriguing scenario in which a municipal public health department needs to decide whether to accept increased contributions to a youth after-school program from a local fast food-chain in exchange for mentioning the chain’s name as part of the (renamed) program. The background section describes how food and beverages are marketed to children and notes that globally, self- regulation models are the most common approach. This case combines real and perceived confl icts of interests for the company and for notoriously cash-strapped public health workers. Woven into the case is the media’s role. The discussion ques- tions invite analyses from the vantage points of different stakeholders and address ways to modify the base scenario, adding layers of complexity.Blacksher’s case focuses on obesity prevention , media campaigns , and stigma. She describes the human and fi nancial toll of obesity worldwide, focusing on chil- dren as an especially vulnerable group. She also presents a range of different policy options to address childhood obesity before charging the reader, acting as a state commissioner for health , to recommend a statewide obesity policy for a dispropor- tionately poor and vulnerable population . The process for reaching consensus on this policy recommendation is common. A task force of a dozen members is appointed, half the seats are reserved for state legislator appointees, and half reserved for public health professionals and community representatives. Due partly to their different background and priorities, the task force disagrees about how intrusive the policy should be. Members settle, however, on a statewide media cam- paign aimed at changing social norms . Still, how hard-hitting should the campaign5 Chronic Disease Prevention and Health Promotion150be? In the discussion questions, readers may consider, among other things, the evi- dence needed to justify different campaign types and if other stakeholders should (or need not) be included in the decision-making process to confer legitimacy.The case by Goldberg and Novick focuses on an intervention program in which task force members grapple with whether the use of stigma might be acceptable under certain circumstances. The authors describe empirical research fi ndings and conceptual arguments that suggest stigma is always correlated with negative health outcomes —especially in otherwise disadvantaged populations , and certainly in the case of obesity . They describe how stigmatizing approaches are based on certain conceptions of personal responsibility that fail to consider the broad underlying structural determinants of obesity. Then the case shifts focus to another situation often encountered in public health practice: applicability of evidence base in mul- tiple settings. Here, a program intended to empower residents to take control of their weight through meal planning, physical activity, and behavioral modifi cation proves effective in controlled studies. The director of the county health department, attracted to the program on grounds of potential cost effectiveness , readily embraces the program. Later, however, during a program meeting, one of the department’s public health nurses expresses concern about an overly strong focus on personal responsibility , which she feels makes the program unfair. Based on her knowledge of the target population , she also feels the program will be rejected . Could the program nonetheless be effective? And how might risks of stigma be minimized? These and related issues form part of the questions section.Whereas the fi rst three cases are set in the United States , the case by Aspradaki et al. takes us to Greece and concerns issues raised by water fl uoridation. The dis- ease burden attributable to preventable tooth decay is laid out along with the risks of using fl uoride . Oral disease is on the rise in low- and middle-income countries , with poorer populations disproportionately affected. The authors describe water fl uorida- tion in different countries before suggesting that the primary ethical tension sur- rounding water fl uoridation arises between the concepts of autonomy and paternalism . The case description puts the reader in the position of Greece’s central oral health director providing a consult to the head of public health programs in the health ministry. Negotiations on a national strategy have been held up by political and organizational digressions and by public skepticism. Still, the health ministry wants to go ahead and put in place a countrywide fl uoridation program. Your task is to identify which stakeholders should be involved, how the different elements of empirical data and ethical values should be considered, and what role economic pressures might play in the decision making.The case by Aleksandrova-Yankulovsak is about banning smoking in public places in Bulgaria . Almost half of the men and a third of the women in Bulgaria are smokers. The case provides context to smoking in Europe and nearby regions before summarizing the regulatory framework that prompted Bulgaria to consider the ban. The political process, threatened by business interests and strife within government departments, is also addressed. The case then poses the question if you, as director of the regional health inspectorate, can guarantee implementation of the new law . Other questions invite discussion on whether the law is the right tool to achieve lowerH. Schmidt151smoking rates , in principle , and how the public might view temporary legal provi- sions that could be repealed if political support dwindles. A further central point is how or whether economic costs can ever be set against cost in human welfare.The cases illustrate but a fraction of the ethical issues that arise in chronic disease prevention and health promotion. Many cases will present differently depending on the country and its culture, infrastructure, health care system, and legal and political system. Similarly, this introduction is far from exhaustive. Yet, when combined, the cases and introduction introduce many central ethical issues that arise in global public health . Analyzing the ethical issues that featured centrally in justifying poli- cies (or in the refusal of policy makers or other actors to change existing policies) will deepen the reader’s engagement and refl ection and, ideally, contribute to better policy and practice in the future.Acknowledgements I am grateful to Anne Barnhill for helpful comments on an earlier version of this introduction.ReferencesAblin, R.J. 2010. The great prostate mistake. New York Times , March 10, A27. Acheson, D. 1998. Independent inquiry into inequalities in health . Department of Health:U.K. Government. http://www.archive.offi cial-documents.co.uk/document/doh/ih/contents. htm . Accessed 20 Oct 2013.Action on Smoking and Health. 2007. Bat’s African footprint . http://www.ash.org.uk/fi les/docu- ments/ASH_685.pdf . Accessed 20 Oct 2013.Bleich, S.N., J.A. Wolfson, and M.P. Jarlenski. 2015. Calorie changes in chain restaurant menu items: Implications for obesity and evaluations of menu labeling. American Journal of Preventative Medicine 48(1): 70–75.Brandt, A.M. 2007. The cigarette century: The rise, fall, and deadly persistence of the product that defi ned America . New York: Basic Books.Centers for Disease Control and Prevention (CDC). 2012. Chronic disease prevention and health promotion . http://www.cdc.gov/chronicdisease/overview/index.htm#ref2 . Accessed 21 Sept 2013.Childress, J.F., R.R. Faden, R.D. Gaare, et al. 2002. Public health ethics: Mapping the terrain. Journal of Law, Medicine & Ethics 30(2): 170–178.Crawford, R. 1977. You are dangerous to your health: The ideology and politics of victim blaming. International Journal of Health Services 7(4): 663–680.Dahlgren, G., and M. Whitehead. 1991. Policies and strategies to promote social equity in health . Stockholm: Institute for Future Studies.Dawson, A., and M.F. Verweij. 2007. Introduction: Ethics, prevention, and public health. In Ethics, prevention and public health , ed. A. Dawson and M. Verweij, 1–12. New York: Oxford University Press.Faculty of Public Health, Royal Colleges of Physicians of the United Kingdom. 2010. What is public health? http://www.fph.org.uk/what_is_public_health . Accessed 20 Oct 2013.Garrett, B.E., S.R. Dube, A. Trosclair, R.S. Caraballo, and T.F. Pechacek. 2011. Cigarette smok- ing—United States, 1965–2008. Morbidity and Mortality Weekly Report. Surveillance Summaries 60(suppl): 109–113.Gigerenzer, G., O. Wegwarth, and M. Feufel. 2010. Misleading communication of risk. British Medical Journal 341: c4830.5 Chronic Disease Prevention and Health Promotionhttp://www.archive.official-documents.co.uk/document/doh/ih/contents.htm http://www.archive.official-documents.co.uk/document/doh/ih/contents.htm http://www.ash.org.uk/files/documents/ASH_685.pdf http://www.ash.org.uk/files/documents/ASH_685.pdf http://www.cdc.gov/chronicdisease/overview/index.htm#ref2 http://www.fph.org.uk/what_is_public_health 152GOP. 2012. Reforming government to serve the people . Available at https://www.gop.com/plat- form/ . Accessed 20 Oct 2013.Gostin, L.O. (ed.). 2010. Public health law and ethics: A reader . Berkeley: University of California Press.Hersch, J., A. Barratt, J. Jansen, L. Irwig, et al. 2015. Use of a decision aid including information on overdetection to support informed choice about breast cancer screening: A randomised con- trolled trial. Lancet 385(9978): 1642–1652.Institute of Medicine. 1988. The future of public health . Washington, DC: National Academy Press.Katz, D.L. 2013. Childhood obesity trends in 2013: Mind, matter, and message. Childhood Obesity 9(1): 1–2.Knowles, J.H. 1977. The responsibility of the individual. Daedalus 106(1): 57–80. Kreis, J., and H. Schmidt. 2013. Public engagement in health technology assessment and coveragedecisions: A study of experiences in France, Germany, and the United Kingdom. Journal of Health Politics, Policy and Law 38(1): 89–122.Krogsbøll, L.T., K.J. Jørgensen, C. Grønhøj Larsen, and P.C. Gøtzsche. 2012. General health checks in adults for reducing morbidity and mortality from disease. Cochrane Database of Systematic Reviews 10: CD009009. http://onlinelibrary.wiley.com/doi/10.1002/14651858. CD009009.pub2/abstract . Accessed 22 Oct 2013.Morain, S., and M.M. Mello. 2013. Survey fi nds public support for legal interventions directed at health behavior to fi ght noncommunicable disease. Health Affairs 32(3): 486–496.Mühlhauser, I. 2007. Ist Vorbeugen besser als Heilen? Zeitschrift für ärztliche Fortbildung und Qualität im Gesundheitswesen 101(5): 293–299. (Mühlhauser I. 2007. Is prevention better than healing? German Journal for Evidence and Quality in Health Care 101(5): 293–299.)Nuffi eld Council on Bioethics. 2007. Public health: Ethical issues . London: Nuffi eld Council on Bioethics.Rosenbrock, R. 2013. Die beste Prävention ist die Lust auf die eigene Zukunft. Der Paritätische , Ausgabe 3/2013, Soziales zählt, 16–18. (Rosenbrock R. 2013. The best prevention is the desire for their own future. The Joint , March edition, Social Matters, 16–18.)Ruger, J.P. 2006. Health, capability, and justice: Toward a new paradigm of health ethics, policy and law. Cornell Journal of Law and Public Policy 15(2): 403–482.Sackett, D.L. 2002. The arrogance of preventive medicine. Canadian Medical Association Journal 167(4): 363–364.Schmidt, H. 2008. Bonuses as incentives and rewards for health responsibility: A good thing? Journal of Medicine and Philosophy 33(3): 198–220.Schmidt, H. 2009. Personal responsibility in the NHS Constitution and the social determinants of health approach: Competitive or complementary? Health Economics, Policy, and Law 4(2): 129–138.Schroeder, S.A. 2007. Shattuck lecture. We can do better—Improving the health of the American people. New England Journal of Medicine 357(12): 1221–1228.Sox, H.C. 2013. The health checkup: Was it ever effective? Could it be effective? Journal of the American Medical Association 309(23): 2496–2497. doi: 10.1001/jama.2013.5040 .U.K. National Screening Committee. 2013. Criteria for appraising the viability, effectiveness and appropriateness of a screening programme . http://www.screening.nhs.uk/criteria . Accessed 22 Oct 2013.U.S. Department of Health and Human Services. 2012. Preventing tobacco use among youth and young adults: A report of the surgeon general . Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Offi ce on Smoking and Health.Venkatapuram, S. 2011. Health justice: An argument from the capabilities approach . Cambridge: Polity Press.Verweij, M., and A. Dawson. 2007. The meaning of ‘public’ in ‘public health’. In Ethics, preven- tion, and public health , ed. A. Dawson and M. Verweij, 13–29. New York: Oxford University Press.Verweij, M., and A. Dawson. 2011. Children’s health, public health. Public Health Ethics 4(2): 107–108.H. Schmidthttps://www.gop.com/platform/ https://www.gop.com/platform/ http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009009.pub2/abstract http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009009.pub2/abstract http://dx.doi.org/10.1001/jama.2013.5040 http://www.screening.nhs.uk/criteria 153Wegwarth, O., and G. Gigerenzer. 2011. Statistical illiteracy in doctors. In Better doctors, better patients, better decisions: Envisioning health care 2020 , ed. G. Gigerenzer and J.A.M. Gray, 137–151. Cambridge, MA: MIT Press.World Bank. 2011. The growing danger of non-communicable diseases: Acting now to reverse course . Washington, DC: World Bank Human Development Network.World Health Organization (WHO). 2002. The World Health Report 2002: Reducing risks, pro- moting healthy life . Geneva: World Health Organization.World Health Organization (WHO). 2003. WHO framework convention on tobacco control . Geneva: World Health Organization.World Health Organization (WHO). 2008. Commission on social determinants of health—fi nal report. Closing the gap in a generation: Health equity through action on the social determi- nants of health . Geneva: World Health Organization. Online at http://www.who.int/social_ determinants/thecommission/fi nalreport/en/index.html .World Health Organization (WHO). 2011. Noncommunicable diseases country profi les 2011 . Geneva: World Health Organization.World Health Organization (WHO). 2012. WHO report on the global tobacco epidemic, 2008: The MPOWER package . Geneva: World Health Organization.World Health Organization (WHO). 2013. The right to health, fact sheet no. 323 . http://www.who. int/mediacentre/factsheets/fs323/en/ . Accessed 8 Dec 2013.Wu, S.Y., and A. Green. 2000. Projection of chronic illness prevalence and cost infl ation . Santa Monica: RAND Health.5.7 Case 1: Municipal Action on Food and Beverage Marketing to YouthCatherine L. Mah Faculty of Medicine Memorial University St. John’s , NL , Canada e-mail: email@example.comBrian Cook Toronto Food Strategy, Toronto Public Health Toronto , ON , CanadaSylvia Hoang Social and Epidemiological Research Department Centre for Addiction and Mental Health Toronto , ON , CanadaEmily Taylor Dalla Lana School of Public Health University of Toronto Toronto , ON , CanadaThis case is presented for instructional purposes only. The ideas and opinions expressed are the authors ’ own. The case is not meant to refl ect the offi cial position ,5 Chronic Disease Prevention and Health Promotionhttp://www.who.int/social_determinants/thecommission/finalreport/en/index.html http://www.who.int/social_determinants/thecommission/finalreport/en/index.html http://www.who.int/mediacentre/factsheets/fs323/en/ http://www.who.int/mediacentre/factsheets/fs323/en/ 154views , or policies of the editors , the editors ’ host institutions , or the authors ’ host institutions .5.7.1 BackgroundChildren are exposed to a greater intensity and frequency of marketing than ever before. Evidence has demonstrated that marketing of food and beverages to children contributes adversely to health, affecting food knowledge, attitudes, dietary habits, consumption practices, and health status. Marketing to children has always raised concerns. But recently, numerous nongovernmental and international organizations and all levels of government have expressed their concern about food and beverage marketing and advertising to children as a public health issue.Often used interchangeably with “advertising,” the term “marketing,” actually encompasses a broader range of issues. The World Health Organization (WHO) ( 2010 ) defi nes marketing as “any form of commercial communication or message that is designed to, or has the effect of, increasing the recognition, appeal and/or consumption of particular products and services. It comprises anything that acts to advertise or otherwise promote a product or service.”Two large-scale global systematic reviews of evidence in the last decade have concluded that food and beverage marketing substantially affects young people and is associated with adverse health outcomes . In 2003, the U.K. Food Standards Agency commissioned a systematic review of the infl uence of food promotion on children’s food-related knowledge, preferences, and behaviors (Hastings et al. 2003 ). WHO updated the report in 2007 and 2009 (Hastings et al. 2007 ; Cairns et al. 2009 ). In 2006, the U.S. Institute of Medicine conducted a systematic review of the infl uences of food and beverage marketing on the diet and diet-related health of children and youth (McGinnis et al. 2006 ). Key fi ndings from these reports follow:• Food and beverages developed for and advertised to young people are predomi- nantly calorie dense and nutrient poor;• Marketing infl uences children’s food and beverage preferences , purchase requests, and short-term consumption, even among young children (ages 2–5 years); and• There is strong evidence that child and youth exposure to television advertising is signifi cantly correlated with poor health status , although suffi cient evidence of a causal link with obesity is not yet available.The authors of the 2009 WHO report suggest that existing research “almost cer- tainly underestimates the infl uence of food promotion” and that more research is needed, especially for newer forms of media (Cairns et al. 2009 ).As part of its global strategy for the prevention and control of noncommunicable diseases (WHO 2004 ), WHO subsequently endorsed policy recommendations for governments to take action on food and beverage marketing to children ( 2010 ,H. Schmidt1552012 ). The recommendations emphasize governments’ key role in developing poli- cies to protect the public interest, including leadership roles in managing intersec- toral processes and negotiating stakeholder rights and responsibilities.The scope of existing policy interventions that address food advertising to chil- dren includes statutory regulation (i.e., general restrictions or outright prohibitions) and industry self-regulatory codes. Globally, industry self-regulatory approaches tend to be the most common approach.Many organizations promote the adoption of comprehensive public policy inter- ventions , with the scope of these interventions ranging from total ad bans (all com- mercial advertising) to food ad bans or junk food ad bans (WHO 2012 ).Other organizations suggest stepwise approaches that target particular expo- sures, products, ages, or specifi c forms of marketing or media. For example, such approaches could include limiting marketing in venues such as schools , restricting junk food , protecting children younger than a certain age, defi ning certain television broadcasts as children’s programs, or restricting promotions in television broadcasts before 10 pm, respectively (WHO 2012 ).In recent years, many food and beverage companies, working with industry asso- ciations, have issued voluntary pledges to alter marketing practices toward children. For example, such pledges typically include criteria for the nutritional quality of foods advertised to children, limitations on the use of licensed characters, and mar- keting in schools. However, critics argue that these types of voluntary changes are not suffi cient to reduce the risks of food marketing to children in a substantive way.Despite this array of interventions, the absence of widespread agreement on the most appropriate form of collective action has led many policy makers to default to inaction.5.7.2 Case DescriptionYou direct the Healthy Public Policy program for a large municipal public health department that recently has come under fi re in a newspaper exposé about contribu- tions from fast food companies to after-school programs for youth that the city government runs. The exposé highlighted the contributions of Big Boss Burger, a local fast food hamburger chain with 12 locations across the city. Big Boss Burger donates cooking equipment to the city’s high-priority, after-school cooking program for 9- to 11-year-olds. Although the program is well-liked by youth, it is regularly threatened by funding cuts. The chain has recently offered to scale-up its annual cash donation to cover all food and equipment costs in exchange for renaming the program “The Big Boss Burger Community Kitchen” and for placing the chain’s logo on all signage and promotional materials.The highly successful Big Boss Burger chain is owned by a beloved, self-made restaurateur who has spent his entire career in the local food industry. Considered a colorful local personality, he frequently sends Twitter updates that refl ect his over-5 Chronic Disease Prevention and Health Promotion156the- top advertising style. One tweet, for example, offered a free sample of the chain’s “quadruple bypass” burger to anyone who visited one of the chain’s loca- tions within the hour.Media spokespersons for the mayor, meanwhile, have reiterated the community benefi ts of cultivating positive partnerships with local businesses. They note that only registered public health nutrition staff run the city’s cooking programs, while insisting that Big Boss Burger has no infl uence whatsoever on city policies or youth curricula.The media furor nevertheless has prompted city offi cials to explore developing a sponsorship policy for municipal child and youth programs. The Medical Health Offi cer has asked you to prepare a briefi ng note outlining the key public health con- siderations that such a sponsorship policy needs to address.You face a dilemma . On the one hand, several years ago your Healthy Public Policy team launched a study of the impact of food and beverage advertising on children . Last year’s update on the study to the Board of Health included a recom- mendation that city-operated venues and programs avoid commercial advertising of food and beverages targeting children younger than 13 years of age. Thus far, the recommendation has not led to any formal policy changes. Municipal employees partly attribute this inaction to the reluctance of local authorities to act when there are no state or national policies that govern sponsorship or marketing restrictions.On the other hand, the fi nancially strapped city relies on engagement with the local business community to fund many city-run programs, including health educa- tion activities. It is also well-known that the owner of Big Boss Burger grew up in a local low- income community and frequently volunteers his time at events in his former neighborhood.5.7.3 Discussion Questions1. What key points will you emphasize in your briefi ng note? How will scientifi c information from past public health reports and decisions infl uence your response? How should ethical considerations infl uence your briefi ng note?2. What population groups are you most concerned about with regard to the spon- sorship policy ? What if the cooking program sponsored by Big Boss Burger was for 14- to 16-year-olds instead of 9- to 11-year-olds? For adults? For children in a high-income neighborhood?3. Does corporate sponsorship constitute food promotion? What benefi ts to the municipality might be derived from Big Boss Burger’s contributions (for exam- ple, local economic benefi ts or having increased public attention and private- sector support of priority neighborhoods)? How should the public health department weigh these benefi ts against population health benefi ts and harm s? Consider your response if Big Boss Burger(a) Had offered its support without the naming rights request; (b) Had instead offered a cash donation to a parents’ association supporting theprogram;H. Schmidt157(c) Was an organic, vegan comfort food restaurant; or (d) Was a large, multinational fast food corporation.4. How will public opinion inform your briefi ng note? How will you handle the situation given that Big Boss Burger is a highly popular fast food chain and that the owner is a local public personality?5. What are (and should be) the roles and responsibilities for various city depart- ments in defi ning the sponsorship policy ? Consider, for example, city depart- ments responsible for public health, parks and recreation, municipal licensing, social services, and economic development .6. Let’s imagine that you are a parent of two girls, ages 6 and 9 years. In an ideal world, how much food and beverage marketing do you think they should be exposed to? How does your perspective as a parent ente r into your professional decisions as director of the Healthy Public Policy program? How about your perspective as a voting citizen or city resident?ReferencesCairns, G., K. Angus, and G. Hastings. 2009. The extent, nature and effects of food promotion to children: A review of the evidence to December 2008. Geneva: World Health Organization. http://whqlibdoc.who.int/publications/2009/9789241598835_eng.pdf . Accessed 29 May 2013.Hastings, G., M. Stead, L. McDermott, et al. 2003. Review of research on the effects of food promo- tion to children: Final report prepared for the food standards agency. Glasgow: Centre for Social Marketing. http://tna.europarchive.org/20110116113217/http:/www.food.gov.uk/multi- media/pdfs/foodpromotiontochildren1.pdf.Accessed 29 May 2013.Hastings, G., L. McDermott, K. Angus, M. Stead, and S. Thomson. 2007. The extent, nature and effects of food promotion to children: A review of the evidence. Technical paper prepared for the World Health Organization. Geneva: World Health Organization. http://whqlibdoc.who.int/ publications/2007/9789241595247_eng.pdf . Accessed 29 May 2013.McGinnis, J.M., J.A. Gootman, and V.I. Kraak (eds.). 2006. Food marketing to children and youth: Threat or opportunity? Committee on Food Marketing and the Diets of Children and Youth, Institute of Medicine of the National Academies. Washington, DC: National Academies Press.World Health Organization (WHO). 2004. Global strategy on diet, physical activity and health. Geneva: World Health Organization. http://www.who.int/dietphysicalactivity/strategy/ eb11344/strategy_english_web.pdf . Accessed 29 May 2013.World Health Organization (WHO). 2010. Set of recommendations on the marketing of foods and nonalcoholic beverages to children. Geneva: World Health Organization. http://whqlibdoc. who.int/publications/2010/9789241500210_eng.pdf . Accessed 29 May 2013.World Health Organization (WHO). 2012. A framework for implementing the set of recommenda- tions on the marketing of foods and non-alcoholic beverages to children. Geneva: World Health Organization. http://www.who.int/entity/dietphysicalactivity/MarketingFramework2012.pdf . Accessed 29 May 2013.5 Chronic Disease Prevention and Health Promotionhttp://whqlibdoc.who.int/publications/2009/9789241598835_eng.pdf http://tna.europarchive.org/20110116113217/http:/www.food.gov.uk/multimedia/pdfs/foodpromotiontochildren1.pdf.Accessed http://tna.europarchive.org/20110116113217/http:/www.food.gov.uk/multimedia/pdfs/foodpromotiontochildren1.pdf.Accessed http://whqlibdoc.who.int/publications/2007/9789241595247_eng.pdf http://whqlibdoc.who.int/publications/2007/9789241595247_eng.pdf http://www.who.int/dietphysicalactivity/strategy/eb11344/strategy_english_web.pdf http://www.who.int/dietphysicalactivity/strategy/eb11344/strategy_english_web.pdf http://whqlibdoc.who.int/publications/2010/9789241500210_eng.pdf http://whqlibdoc.who.int/publications/2010/9789241500210_eng.pdf http://www.who.int/entity/dietphysicalactivity/MarketingFramework2012.pdf 1585.8 Case 2: Obesity Prevention in Children : Media Campaigns , Stigma, and EthicsErika Blacksher Department of Bioethics and Humanities University of Washington Seattle , WA , USA e-mail: firstname.lastname@example.orgThis case is presented for instructional purposes only. The ideas and opinions expressed are the author ’ s own. The case is not meant to refl ect the offi cial position , views , or policies of the editors , the editors ’ host institutions , or the author ’ s host institution .5.8.1 BackgroundWorldwide obesity has doubled since 1980 and kills some 2.8 million adults each year (World Health Organization [WHO] 2012 ). Childhood obesity also has increased at alarming rates with some 42 million children estimated to be over- weight (WHO 2013 ). Among Organisation for Economic Cooperation and Development (OECD) countries, the United States has the highest rate of obesity (OECD 2012 ). More than 35 % of adults and almost 17 % of children are obese (Ogden et al. 2012 ), with especially high rates among poor and minority children (Centers for Disease Control and Prevention [CDC] 2012 ).Childhood obesity has serious short- and long-term health consequences. Obese children are more likely to have risk factors for cardiovascular disease, including high cholesterol and blood pressure; type 2 diabetes; skeletal problems; sleep apnea; and mental health issues, such as low self-esteem and depression (CDC 2012 ; Reilly et al. 2003 ). Children now account for half of all new cases of type 2 diabetes. Obese children are also subject to systematic discrimination (Strauss 2002 ). More than 50 % of overweight children become obese adults who experience elevated health risks for heart disease, stroke, diabetes, osteoporosis, lower-body disability, some types of cancer, and premature mortality (Freedman 2011 ; CDC 2012 ).The burdens of obesity are also economic. Rising health care costs are mostly driven by obesity-related costs . Estimates indicate that in 2008 some 10 % of medi- cal spending in the United States was related to obesity, amounting to as much as $147 billion (Finkelstein et al. 2009 ). Experts estimate obesity-related costs will account for 21 % of medical spending by 2018 if obesity rates continue to rise (United Health Foundation 2009 ).As the human and fi nancial costs of obesity have become better recognized, gov- ernment offi cials and public health leaders increasingly have called for strong action. Comprehensive approaches that act on environmental and social determi-H. Schmidt159nants of food choice and activity level are widely recommended (OECD 2012 ). The complexity of such an approach is refl ected in the following recommended policies and strategies: taxing unhealthy foods and beverages, such as soda and snack food, to make them cost prohibitive; providing agricultural subsidies to lower the cost of healthy foods, such as fresh produce and whole grains; setting standards to lower sodium levels and prohibit the use of trans fatty acids in food products; banning unhealthy foods from public schools and child care facilities; restricting or banning the advertising of unhealthy foods to children ; posting calorie counts on restaurant and take-out menus; using “counter-advertising” to show the harmful effects of unhealthy foods; redesigning communities and streets to incorporate parks, sidewalks, and bike paths; and reducing sedentary behavior by limiting time view- ing television and playing computer games (Frieden et al. 2010 ; Butland et al. 2007 ).Children’s status as developing agents further complicates childhood obesity prevention . Parents have primary responsibility for rearing children and consider- able discretion over cultural and lifestyle matters, including many daily decisions that directly affect a child’s food and activity-related environments and behaviors (Blacksher 2008 ). Some measures would likely confer benefi t regardless of parental behavior (e.g., banning food advertising to children or removing trans fats from packaged foods). But others will have their intended effect only if parents make certain choices, some of which will require that they change their health-related habits.Many preventive measures will be controversial because they involve govern- ment action and seek to shape personal choice . Perhaps the least controversial of the measures enable healthier choices by providing people with information and mak- ing healthy options more available and affordable; however, many are more coer- cive, ranging from those that eliminate and restrict choice to those that guide choice through disincentives and default policies ( Nuffi eld Council on Bioethics 2007 ). Intervening in voluntary choices where effects impose no harm to others constitutes strong paternalism and is diffi cult though not impossible to justify (Childress et al. 2002 ). However, society may justifi ably intervene to prohibit behaviors that expose others to serious harms , and this “ harm principle ” has been appealed to as the basis for removing children from homes where parental practices are judged to contribute to severe childhood obesity and attendant comorbidities (Murtagh and Ludwig 2011 ). Removing a child from the home poses other potential harms , further com- plicating the ethical dilemma (Black and Elliott 2011 ). These ethical considerations in combination with the diffi culty of changing health habits makes obesity preven- tion one of the more challenging public health priorities of the twenty-fi rst century.5 Chronic Disease Prevention and Health Promotion1605.8.2 Case DescriptionYour state is the poorest in the nation with high rates of childhood poverty, obesity , and diabetes . Located in the southeastern part of the United States in what is known as the “stroke belt,” adults disproportionately suffer from stroke and its risk fac- tors—hypertension, high cholesterol, diabetes, and obesity. As the state’s new com- missioner of health, the governor has tasked you with making obesity prevention a public health priority. The governor is concerned about public health and rising health care costs . More than 50 % of the state’s children and some 20 % of adults are enrolled in Medicaid (a federal-state program that provides health care services for low-income Americans), making it the largest item in the state budget.The governor has requested that you convene and chair a 12-member task force to make recommendations for a statewide obesity prevention strategy. Six seats are reserved for state legislator appointees because the recommendations will need political support to be implemented. The other seats are reserved for public health, health care, and community representatives. For several months, task force mem- bers debated measures that eliminate or restrict adult choice through government action , such as taxes and bans on unhealthy foods and drinks. Those who favored such measures argued they would be the most effective, citing the success of tobacco taxes and smoking bans in reducing smoking , and could be justifi ed on grounds that obesity-related costs constitute an economic harm to others (Pearson and Lieber 2009 ). Yet, many task force members, particularly elected representatives, found such measures objectionable forms of government intrusion into adult choices.Task force members did, however, agree to tackle obesity prevention in children on grounds that the state has a role in protecting them. To that end, they endorsed measures to improve school lunches and to remove vending machines that sell soda and other sugary beverages from public school grounds. Task force members also wanted to invest in a statewide media campaign about the causes and harms of childhood obesity because they believed it would raise awareness and promote informed choices . They also thought a media campaign would help to change social norms , which they deemed essential to long-term change in their state, where fried and fatty foods are part of the cultural heritage.Task force members cannot, however, agree on the orientation of such a cam- paign. Some favor an approach used by a nearby state that has attracted attention for its graphic depiction of obese and unhappy children accompanied by hard-hitting messages , such as “It’s hard to be a little girl if you’re not.” Opponents believe the campaign blames the victims and further stigmatizes obese children . They propose instead an approach that highlights environmental barriers to healthy choices and depicts unhealthy food as the culprit, not those who consume it. But proponents of the more hard-hitting approach say it is honest about the facts and highlights the essential role of parents in regulating children’s behavior. To support their case, they cite the use of similarly graphic media campaigns in tobacco cessation efforts and note that public health efforts have often relied on stigma as a tool of disease pre- vention , despite the controversy (Bayer 2008 ; Burris 2008 ). The task force has for- mulated a series of questions to take up at the next meeting.H. Schmidt1615.8.3 Discussion Questions1. What harms are associated with childhood obesity ? 2. Are the harms of obesity and tobacco use analogous? Is the economic cost of obe-sity a harm to others in the same way that secondhand smoke is a harm to others? 3. Do public media campaigns that depict images of obese children stigmatizethem? What is stigma? 4. Is it ever ethically permissible to use stigmatization as a tool of disease preven-tion and health promotion ? If so, in what sort of cases? Should children ever be the targets of stigmatization?5. Do public media campaigns that highlight the role of parents in regulating chil- dren’s food and activity-related environments and choices blame the victims?6. Should the task force consider gathering community input, particularly from people who are overweight or obese, about the sorts of messages they would fi nd effective in changing their health habits and also fi nd ethically acceptable? If so, should children be included in these focus groups? If so, at what age?ReferencesBayer, R. 2008. Stigma and the ethics of public health: Not can we but should we. Social Science & Medicine 67(3): 463–472. doi: 10.1016/j.socscimed.2008.03.017 .Blacksher, E. 2008. Children’s health inequalities: Ethical and political challenges to seeking social justice. Hastings Center Report 38(4): 28–35.Black, W., and R.L. Elliott. 2011. Childhood obesity and child neglect. Journal of the Medical Association of Georgia 100(4): 24–25.Burris, S. 2008. Stigma, ethics, and policy: A commentary on Bayer’s “Stigma and the ethics of public health: Not can we but should we”. Social Science & Medicine 67(3): 473–475.Butland, B., S. Jebb, P. Kopelman, et al. 2007. Foresight. Tackling obesities: Future choices. London: Government Offi ce for Science.Centers for Disease Control and Prevention (CDC). 2012. Adolescent and school health: Childhood obesity facts. http://www.cdc.gov/healthyyouth/obesity/facts.htm . Accessed 11 June 2013.Childress, J.F., R.R. Faden, R.D. Gaare, et al. 2002. Public health ethics: Mapping the terrain. Journal of Law Medicine & Ethics 30(2): 170–178.Freedman, D.S. 2011. Obesity—United States, 1988–2008. Morbidity and Mortality Weekly Report. Surveillance Summaries 60(01): 73–77.Finkelstein, E.A., J.G. Trogdon, J.W. Cohen, and W. Dietz. 2009. Annual medical spending attrib- utable to obesity: Payer- and service-specifi c estimates. Health Affairs 28(5): w822–w831.Frieden, T.R., W. Dietz, and J. Collins. 2010. Reducing childhood obesity through policy change: Acting now to prevent obesity. Health Affairs 29(3): 357–363.Murtagh, L., and D.S. Ludwig. 2011. State intervention in life-threatening childhood obesity. Journal of the Medical Association 306(2): 206–207.Nuffi eld Council on Bioethics. 2007. Public health: Ethical issues. http://www.nuffi eldbioethics. org/public-health . Accessed 11 June 2013.Organisation for Economic Cooperation and Development (OECD). 2012. Obesity update 2012. http://www.oecd.org/health/49716427.pdf . Accessed 11 June 2013.5 Chronic Disease Prevention and Health Promotionhttp://dx.doi.org/10.1016/j.socscimed.2008.03.017 http://www.cdc.gov/healthyyouth/obesity/facts.htm http://www.nuffieldbioethics.org/public-health http://www.nuffieldbioethics.org/public-health http://www.oecd.org/health/49716427.pdf 162Ogden, C.L., M.D. Carroll, B.K. Kit, and K.M. Flegal. 2012. Prevalence of obesity in the United States, 2009–2010. National Center for Health Statistics Data Brief, no. 82. http://www.cdc. gov/nchs/data/databriefs/db82.pdf . Accessed 11 June 2013.Pearson, S.D., and S.R. Lieber. 2009. Financial penalties for the unhealthy? Ethical guidelines for holding employees responsible for their health. Health Affairs 28(3): 845–852.Reilly, J.J., E. Methven, Z.C. McDowell, et al. 2003. Health consequences of obesity. Archives of Disease in Childhood 88(9): 748–752.Strauss, R.S. 2002. Childhood obesity and self-esteem. Pediatrics 105(1): 152–155. United Health Foundation. 2009. The future costs of obesity: National and state estimates of theimpact of obesity on direct health care expenses. United Health Foundation in collaboration with the American Public Health Association and Partnership for Prevention. http://www. nccor.org/downloads/CostofObesityReport-FINAL.pdf . Accessed 11 June 2013.World Health Organization (WHO). 2012. Obesity and overweight (Fact Sheet no. 311), updated March 2013. http://who.int/mediacentre/factsheets/fs311/en/ . Accessed 11 June 2013.World Health Organization (WHO). 2013. Global strategy on diet, physical activity and health. Childhood overweight and obesity. http://who.int/dietphysicalactivity/childhood/en/ . Accessed 11 June 2013.5.9 Case 3: Obesity Stigma in Vulnerable and Marginalized GroupsDaniel S. Goldberg Department of Bioethics and Interdisciplinary Studies, Brody School of Medicine East Carolina University Greenville , NC , USA e-mail: email@example.comLloyd Novick Brody School of Medicine East Carolina University Greenville , NC , USAThis case is presented for instructional purposes only. The ideas and opinions expressed are the authors ’ own. The case is not meant to refl ect the offi cial position , views , or policies of the editors , the editors ’ host institutions , or the authors ’ hos t institutions .5.9.1 BackgroundFor empirical and normative reasons, stigma is an enormous public health problem that can have devastating psychosocial impact (Vanable et al. 2006 ; Chapple et al. 2004 ). Moreover, there is evidence that even after controlling for confounders,H. Schmidthttp://www.cdc.gov/nchs/data/databriefs/db82.pdf http://www.cdc.gov/nchs/data/databriefs/db82.pdf http://www.nccor.org/downloads/CostofObesityReport-FINAL.pdf http://www.nccor.org/downloads/CostofObesityReport-FINAL.pdf http://who.int/mediacentre/factsheets/fs311/en/ http://who.int/dietphysicalactivity/childhood/en/ 163stigma is robustly correlated with adverse health outcomes (Vardy et al. 2002 ; Puhl and Brownell 2003 ). Stigma increases human suffering and diminishes health, both of which anchor ethical concerns. However, its ethical defi ciencies are not solely a function of its health effects; as Burris notes, “even if [stigma] had no adverse effects on health … it may readily be seen as repugnant in a humane society” (Burris 2002 ; Courtwright 2013 ).According to Hatzenbuehler et al. ( 2013 ), stigma in a public health context con- sists of two central components: (1) an in-group marks an out-group as different on the basis of some common demographic characteristic, and (2) the in-group assigns a negative evaluation to the characteristic. Stigma is therefore intimately connected to entrenched social power structures (Link and Phelan 2006 ; Scambler 2006 ). Unsurprisingly, while precise estimates are lacking, evidence suggests that the burden of such stigma is unequally distributed along the social gradient , and that already disadvantaged groups are more likely to experience more intense levels of stigma (Scambler 2006 ; Shayne and Kaplan 1991 ). The prospect of compound dis- advantage and inequalities renders stigma a critical issue for public health ethics, one that strongly implicates concerns of distributive and social justice (Powers and Faden 2006 ; Courtwright 2009 ).Recent data shows that the prevalence of obesity is 35.7 % in the United States (Ogden et al. 2012 ) and 12.0 % globally (Stevens et al. 2012 ). Tracking these high estimates, obesity stigma is one of the common and ethically alarming health stig- mas (Puhl and Heuer 2009 ; Puhl and Brownell 2003 ). Puhl and Heuer ( 2010 ) expressly link the commonality of obesity stigma to the emphasis on personal responsibility in the United States, which is the subject of an active debate (Wikler 2002 ). This debate has nineteenth century roots but is ongoing (Leichter 2003 ) and infl uences public perceptions on whether collective action in the name of public health is warranted. Moreover, such perceptions vary with particular public health problems. For example, although many advocate for greater individual responsibil- ity in wearing seat belts, few contend that such responsibility eliminates the need for guardrails and speed limits. The perceived linkages between obesity and personal responsibility suggest that approaches to health promotion emphasizing the latter run a signifi cant risk of intensifying obesity stigma (Puhl and Heuer 2010 ). Goldberg ( 2012 ) argues that such risk renders these approaches ethically suboptimal.In addition, it is well recognized that background socioeconomic conditions are primary components of obesity-creating environments (McLaren 2007 ; Pickett et al. 2005 ). The fact that socioeconomic conditions have an immense impact in determining patterns of obesity among and within populations suggests reasons for doubting that public health interventions targeted at individual lifestyle change will be particularly effective in countering obesity (MacLean et al. 2009 ). Indeed, the evidence obtained from analysis of other major risk factors, such as smoking , strongly suggests a lack of longitudinal effi cacy for such interventions (Jarvis and Wardle 2006 ; Ebrahim and Smith 2001 ; Rose 1985 ).There exists signifi cant debate over the effectiveness of stigmatization in chang- ing risky health behaviors. Some commentators argue that the denormalization and stigmatization of smoking has produced positive public health consequences given5 Chronic Disease Prevention and Health Promotion164the overall decline in incidence in the United States (Bayer 2008 ; Bell et al. 2010 ) and in parts of Europe (Ritchie et al. 2010 ). One leading bioethicist even recently endorsed a kind of “stigmatization lite” as a tool to reduce obesity (Callahan 2013 ). Although the evidence for effi cacy of stigma as a means to enhancing public health in general remains in dispute, the evidence as to obesity overwhelmingly suggests that stigma is more likely to exacerbate obesity than to reduce it (Puhl et al. 2013 ; Puhl and Heuer 2010 ).Finally, there is excellent evidence that interventions that target individual behav- ior change have the unfortunate tendency to expand health inequalities . Capewell and Graham ( 2010 ) term such interventions “agentic” because the extent of their benefi ts depends on the resources the individual agent can bring to bear. Thus, for example, even when the least well-off are targeted, smoking cessation programs disproportionately benefi t the affl uent. The result is that effective programs target- ing lifestyle change can unintentionally expand health inequalities , a fact that raises signifi cant concerns of justice .Ultimately, though efforts to counter obesity are critically needed, it is all too easy to implement public health interventions that intensify obesity stigma, expand health inequalities , and take little account of the role background social conditions play in structuring patterns of obesity and limiting health choices. Efforts to address obesity must therefore grapple with signifi cant ethical issues centering primarily on justice and on health equity .5.9.2 Case DescriptionThe Brennan County Health Department (BCHD) is considering a new health pro- motion program to ameliorate the high and growing rates of adult obesity in the county (prevalence and incidence of 38 and 3.5 %). The program emphasizes the need to “Take Control” by (1) assessing weight; (2) losing weight; and (3) prevent- ing weight gain (Centers for Disease Control and Prevention 2012 ). It highlights the signifi cance of personal responsibility in countering obesity and aims to empower individuals to implement lifestyle change. The program consists of twice-weekly meetings facilitated by a nutritionist held over 8 weeks, with screening performed by a family nurse practitioner. The regimen consists of modules on meal planning, physical activity, behavioral modifi cation, and cooking instruction. The meetings would occur at 6:30 pm at Brennan County Memorial Hospital.The hospital is located in the town of Bernsville, which sits in the northwestern corner of the county. Brennan County is rural and geographically large, with a small population spread across large distances. Multiple bodies of water traverse the county. Road quality is uneven. Educational attainment is low, with only 43 % of residents having completed some college. Thirty-eight percent of children in Brennan County live in poverty, and the violent crime rate per 100,000 people is 605 (the national benchmark is 73). Unemployment is 14.2 %. Farming is a chief eco- nomic activity, with several migrant labor camps existing in the southeastern part ofH. Schmidt165the county. In terms of demographics, 40 % of Brennan County residents are Caucasian, 35 % are African-American , 14 % are Hispanic/Latino, 10 % are Native American, and 1 % is Asian/Asian-American.The BCHD obesity program is based on reasonably good evidence. Several con- trolled studies of model programs have demonstrated both reduction in body weight and prevention of weight gain. Such effects decreased over time, but statistically signifi cant improvements were maintained at 8-month follow-up. Ongoing studies are intended to assess effect endurance at 18 and 24 months postintervention.At a recent BCHD meeting, Pauline, a public health nurse employed by the health department, expressed concern about the implementation of the program. Surprised, several attendees ask Pauline why she is hesitant, and she replies that she is concerned that the obesity program’s emphasis on personal responsibility and lifestyle change might not be received well in a resource-poor county that serves multiple vulnerable populations, many of whom have documented levels of medical and institutional mistrust. The BCHD director, James, admits that Pauline’s con- cerns are legitimate, but he also notes the evidence suggesting the intervention’s effi cacy. He argues that such results are so important that they justify immediate implementation. James also notes that several county commissioners have publicly declared an obesity crisis in Brennan County and have privately indicated to him that BCHD is expected to lead a transparent and vigorous response. In addition, James points out that the county does not have the funds to devote to more upstream interventions and they have several staff already trained in lifestyle change methods, so that the costs could be low.Pauline shakes her head and says that while it is critical to address obesity in Brennan County, the program ignores the environmental and background conditions in which the most at-risk communities in Brennan County live, work, and play . She reiterates her concern that the program as it currently stands is unfair.5.9.3 Discussion Questions1. To what extent does the program risk creating or intensifying obesity stigma against marginalized and vulnerable groups in Brennan County? Why does this matter ethically?2. Why are the social and economic conditions residents of Brennan County expe- rience relevant to an ethical assessment of the obesity program?3. How does the rural nature of Brennan County infl uence the ethical analysis of the program?4. What concerns related to justice and/or health equity does the program raise? 5. How should obesity interventions be structured to minimize risks of stigma? 6. To what extent should public health interventions intended to counter obesitytarget upstream social determinants of obesity and obesity-related diseases?5 Chronic Disease Prevention and Health Promotion166ReferencesBayer, R. 2008. Stigma and the ethics of public health: Not can we but should we. Social Science & Medicine 67(3): 463–472. doi: 10.1016/j.socscimed.2008.03.017 .Bell, K., A. Salmon, M. Bowers, J. Bell, and L. McCullough. 2010. Smoking, stigma and tobacco ‘denormalization’: Further refl ections on the use of stigma as a public health tool. Social Science & Medicine 70(6): 795–799.Burris, S. 2002. Disease stigma in U.S. public health law. Journal of Law, Medicine & Ethics 30(2): 179–190.Callahan, D. 2013. Obesity: Chasing an elusive epidemic. Hastings Center Report 43(1): 34–40. Capewell, S., and H. Graham. 2010. Will cardiovascular disease prevention widen health inequali-ties? PLoS Medicine 7(8): e1000320. Centers for Disease Control and Prevention. 2012. Healthy weight. http://www.cdc.gov/healthy-weight . Accessed 20 Dec 2012. Chapple, A., S. Ziebland, and A. McPherson. 2004. Stigma, shame, and blame experienced bypatients with lung cancer: Qualitative study. British Medical Journal 328(7454): 1470. Courtwright, A.M. 2009. Justice, stigma, and the new epidemiology of health disparities. Bioethics23(2): 90–96. Courtwright, A. 2013. Stigmatization and public health ethics. Bioethics 27(2): 74–80. Ebrahim, S., and G.D. Smith. 2001. Exporting failure? Coronary heart disease and stroke in devel-oping countries. International Journal of Epidemiology 30(2): 201–205. Goldberg, D.S. 2012. Social justice, health inequalities and methodological individualism in U.S.health promotion. Public Health Ethics 5(2): 104–115. Hatzenbuehler, M.L., J.C. Phelan, and B.G. Link. 2013. Stigma as a fundamental cause of popula-tion health inequalities. American Journal of Public Health 103(5): 813–821. Jarvis, M.J., and J. Wardle. 2006. Social patterning of individual behaviors: The case of cigarettesmoking. In Social determinants of health , 2nd ed, ed. M.G. Marmot and R.G. Wilkinson, 224–237. Oxford/New York: Oxford University Press.Leichter, H.M. 2003. “Evil habits” and “personal choices”: Assigning responsibility for health in the 20th century. Milbank Quarterly 81(4): 603–626.Link, B.G., and J.C. Phelan. 2006. Stigma and its public health implications. Lancet 367(9509): 528–529.MacLean, L., N. Edwards, M. Garrard, N. Sims-Jones, K. Clinton, and L. Ashley. 2009. Obesity, stigma and public health planning. Health Promotion International 24(1): 88–93.McLaren, L. 2007. Socioeconomic status and obesity. Epidemiologic Reviews 29: 29–48. Ogden, C.L., M.D. Carroll, B.K. Kit, and K.M. Flegal. 2012. NCHS Data Brief No. 82: Prevalenceof obesity in the United States, 2009–2010. http://www.cdc.gov/nchs/data/databriefs/db82.pdf . Accessed 10 Apr 2013.Pickett, K.E., S. Kelly, E. Brunner, T. Lobstein, and R.G. Wilkinson. 2005. Wider income gaps, wider waistbands? An ecological study of obesity and income inequality. Journal of Epidemiology and Community Health 59(8): 670–674.Powers, M., and R. Faden. 2006. Social justice: The moral foundations of public health and health policy. New York: Oxford University Press.Puhl, R.M., and K.D. Brownell. 2003. Psychosocial origins of obesity stigma: Toward changing a powerful and pervasive bias. Obesity Reviews 4(4): 213–227.Puhl, R.M., and C.A. Heuer. 2009. The stigma of obesity: A review and update. Obesity 17(5): 941–964.Puhl, R.M., and C.A. Heuer. 2010. Obesity stigma: Important considerations for public health. American Journal of Public Health 100(6): 1019–1028.Puhl, R., J.L. Peterson, and J. Luedicke. 2013. Motivating or stigmatizing? Public perceptions of weight-related language used by health providers. International Journal of Obesity 37(4): 612–629.H. Schmidthttp://dx.doi.org/10.1016/j.socscimed.2008.03.017 http://www.cdc.gov/healthyweight http://www.cdc.gov/healthyweight http://www.cdc.gov/nchs/data/databriefs/db82.pdf 167Ritchie, D., A. Amos, and C. Martin. 2010. “But it just has that sort of feel about it, a leper”— Stigma, smoke-free legislation and public health. Nicotine & Tobacco Research 12(6): 622–629.Rose, G. 1985. Sick individuals and sick populations. International Journal of Epidemiology 14(1): 32–38.Scambler, G. 2006. Sociology, social structure and health-related stigma. Psychology, Health & Medicine 11(3): 288–295.Shayne, V.T., and B.J. Kaplan. 1991. Double victims: Poor women and AIDS. Women & Health 17(1): 21–37.Stevens, G.A., G.M. Singh, Y. Lu, et al. 2012. National, regional, and global trends in adult over- weight and obesity prevalences. Population Health Metrics 10(1): 22.Vanable, P.A., M.P. Carey, D.C. Blair, and R.A. Littlewood. 2006. Impact of HIV-related stigma on health behaviors and psychological adjustment among HIV-positive men and women. AIDS and Behavior 10(5): 473–482.Vardy, D., A. Besser, M. Amir, B. Gesthalter, A. Biton, and D. Buskila. 2002. Experiences of stig- matization play a role in mediating the impact of disease severity on quality of life in psoriasis patients. British Journal of Dermatology 147(4): 736–742.Wikler, D. 2002. Personal and social responsibility for health. Ethics & International Affairs 16(2): 47–55.5.10 Case 4: Water Fluoridation: The Example of GreeceAikaterini A. Aspradaki Joint Graduate Programme in Bioethics University of Crete Crete , Greece e-mail: firstname.lastname@example.orgIoannis Tzoutzas School of Dentistry National and Kapodistrian University of Athens Athens , GreeceMaria Kousis Center for Research and Studies in Humanities, Social Sciences and Pedagogics University of Crete Crete , GreeceAnastas Philalithis Department of Social Medicine, Faculty of Medicine University of Crete Crete , GreeceThis case is presented for instructional purposes only. The ideas and opinions expressed are the authors ’ own. The case is not meant to refl ect the offi cial position , views , or policies of the editors , the editors ’ host institutions , or the authors ’ host institutions .5 Chronic Disease Prevention and Health Promotion1685.10.1 BackgroundDental caries is a condition with major public health impact worldwide. In most industrialized countries, it affects 60–90 % of school children and most adults, whereas in several Asian and Latin American countries, it is the most prevalent oral disease (Petersen and Lennon 2004 ). Dental caries signifi cantly affects individuals and communities, leading to pain and discomfort, impairment of oral and general health, and reduced quality of life. It also highly correlates with health systems, living conditions, behavioral and environmental factors, and implementation of preventive measures (World Health Organization [WHO] 2005 , 2007 ; Shariati et al. 2013 ). In low- and middle-income countries , the prevalence of oral diseases is on the rise; and in all countries, the greatest burden of oral diseases falls on disadvantaged and poor populations (Petersen 2008 ). Although oral disease ranks as the fourth most expensive disease to treat (WHO 2007 ), effective prevention and health promotion measures can greatly reduce the cost of dental treatment . As a result, the WHO has emphasized the importance of developing global oral health policies , especially the implementation of fl uoride programs to prevent dental caries (WHO 2012 ).For the past 60 years, fl uoride use has consistently proven to be one of public health’s most successful interventions (Clarkson et al. 2000 ). Used in tablets, mouthwash, toothpaste, gels or varnishes, fl uoride also may be added to salt or drinking water to protect against dental caries (WHO 2011 ). High fl uoride levels in drinking water (>10 mg l −1 ), are associated with dental fl uorosis, a discoloring or mottling of tooth enamel, while levels below 0.1 mg l −1 are associated with higher levels of dental decay (Edmunds and Smedley 1996 ). A level of about 1 mg l −1 is associated with lower incidence of dental caries, particularly in children (Fawell et al. 2006 ). Water fl uoridation adjusts the fl uoride concentration of a public water supply to an optimal level to prevent dental caries (WHO 2002 ). Countries such as Australia, Malaysia, Ireland, Spain , the United Kingdom , and the United States use water fl uoridation, delivering fl uoride to about 300 million persons worldwide (Clarkson et al. 2000 ).
Despite the demonstrated effectiveness of fl uorides in preventing dental carries, public discussions about the effectiveness of water fl uoridation continue (Awofeso 2012 ; Rugg-Gunn and Do 2012 ). Several publications discuss the benefi ts and harms of water fl uoridation (McDonagh et al. 2000 ; European Commission, Directorate General for Health and Consumers , Scientifi c Committee on Health and Environmental Risks 2011 ; Phillips et al. 2011 ; Community Preventive Services Task Force 2013 ). However, a lack of good-quality evidence on the potential bene- fi ts and harms has been reported ( Nuffi eld Council on Bioethics 2007 ). Moreover, with the advent of genomic techniques in studying oral diseases , susceptibility to dental caries has been shown in part to be due to genetic variations (Eng et al. 2012 ), increasing in this way the complexity and the multicausality of dental caries.
Implementing water fl uoridation programs can be controversial and generate tension between competing ethical principles and values —primarily confl icts between the principles of paternalism and autonomy . While water fl uoridation is
considered to be a “test case” in the discussion about the paternalism of “collective decisions” (Dworkin 1988 ), appeals to paternalism point to water fl uoridation’s benefi ts for entire communities (e.g., health needs of children , reduction in health risks and health inequalities ). However, those who prioritize autonomy point out that water fl uoridation intervenes in an important area of personal life without the consent of those affected, essentially coercing adults to lead healthy lives (Nuffi eld Council on Bioethics 2007 ). Despite the controversy, water fl uoridation is “the most celebrated example” of “collective action/ effi ciency ” to justify public health pro- grams and policies (Faden and Shebaya 2010 ). In deliberative democracies, govern- ments tend to address the confl ict between paternalism and autonomy by focusing on elements of procedural justice —rational explanations, transparency of the deci- sion-making process , and involvement of individuals and stakeholder groups in decision making (Nuffi eld Council on Bioethics 2007 ).
Greece , a coastal Mediterranean country in southeastern Europe, has nearly 11 million people. Among 12-year-olds, the average number of dental caries —mea- sured as the number of decayed, missing, or fi lled teeth—is 2.07 per child (Kravitz and Treasure 2009 ). Public institutions such as universities, hospitals, and health centers of the National Health System provide limited oral health care . Most oral health care takes place in private clinics, where dental patients pay the entire cost of care. Oral health care constitutes an estimated one-third of the total expenditure on private health care in Greece (Kravitz and Treasure 2009 ). Since 2009, Greece has faced a severe fi scal crisis. In providing health care, public health authorities have to deal with severe budget limitations. The fi nancial crisis is also straining the abil- ity of individuals to pay for private sector dental treatment .
The Greek central government regulates many public health programs, including oral disease prevention and oral health promotion policies , but implementation is local. Although the government mandated water fl uoridation in 1974, as of 2013 the program had not been implemented because of diffuse public resistance to such interventions. In 2008, a special commission proposed to the Ministry of Health and Social Solidarity to include water fl uoridation in the national strategy for public health (Ministry of Health and Social Solidarity 2008 ). Given the long hiatus in implementing the program, reasonable questions could be raised about its justifi ca- tion, political legitimization, and social acceptance. A two-part study on these ques- tions was carried out (Aspradaki 2012 ). It included interviews with key fi gures in the dental community from academia, the professions , and trade unions. It also included a systematic content analysis of all mentions of water fl uoridation by the involved actors (e.g., dental professionals, policy makers ) reported in the Journal of the Hellenic Dental Association for 1983 through 2011. The results showed strong skepticism among professionals about the program’s feasibility—refl ecting the public’s concerns over this issue. Signifi cant concerns were about a lack of techni- cal infrastructure and organizational problems in the institutions that would implement water fl uoridation. The vigorousness of the opposing arguments in the autonomy / paternalism debate in terms of justice , procedural justice , and public interest added to the skepticism. Concerns were also raised about the overall
5 Chronic Disease Prevention and Health Promotion
importance of oral health for human life, the signifi cance of prevention in dental care, and the concept of dental caries as an epidemic.
5.10.2 Case Description
You serve as the central oral health policy director . One morning you receive a call from Dr. Papadakis, head of the Public Health Programs and Policies Division at the Ministry of Health and Social Solidarity . Dr. Papadakis is considering implement- ing mandatory water fl uoridation but is concerned about the many diffi culties he may confront (i.e., ethical, legal, political and social challenges). Dr. Papadakis asks you to provide input about what to consider before mandatory water fl uoridation is implemented in Greece .
5.10.3 Discussion Questions
1. Who are the stakeholders to consider in deciding if this program should be implemented? What are their values , perspectives, and primary interests?
2. How should the relevant values be considered, in particular, scientifi c evidence, ethical concerns, and economic factors?
3. Do public health institutions have special obligations to protect oral health? 4. When public health interventions are environmental, should public participation
and democratic deliberation be considered in the decision-making processes? 5. How important is transparency about the benefi ts and risks of these interven-
tions, in the light of the rapid progress and the tremendous achievements in life sciences and biotechnologies?
6. How would the rationale for such public health interventions change if the gov- ernment and individuals were not facing a severe fi nancial crisis?
Acknowledgements We thank the peer reviewers and editors for their comments. We also thank Professor Stavroula Tsinorema, Director of Studies of the Joint Graduate Programme in Bioethics , University of Crete, Crete, Greece, for her valuable support.
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Fawell, J., K. Bailey, J. Chilton, E. Dahi, L. Fewtrell, and Y. Magara. 2006. Fluoride in drinking– water . London: World Health Organization, IWA Publishing.
Kravitz, A.S., and E.T. Treasure. 2009. Manual of dental practice (version 4.1). See esp. pp. 171– 178 part 11: “Individual Country Sections -Greece” Council of European Dentists: Cardiff. http://abdentist.com/en/assets/fi les/man_dent_prac.pdf . Accessed 15 Nov 2012.
McDonagh, M.S., P.F. Whiting, P.M. Wilson, et al. 2000. Systematic review of water fl uoridation. British Medical Journal 321(7265): 855–859.
Ministry of Health and Social Solidarity. 2008. National plan of action on public health. National plan of action on oral health 2008–2012. http://www.moh.gov.gr/articles/health/domes-kaidra- seis-gia-thn-ygeia-ethnika-sxedia-drashs/95-ethika-sxedia-drashs?fdl=222 . Accessed 3 June 2015.
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Petersen, P.E. 2008. World Health Organization global policy for improvement of oral health— World Health Assembly 2007. International Dental Journal 58(3): 115–121.
Petersen, P.E., and M.A. Lennon. 2004. Effective use of fl uorides for the prevention of dental car- ies in the 21st century: The WHO approach. Community Dentistry and Oral Epidemiology 32(5): 319–321.
Phillips, C., B. Amphlett, and I.J. Robbé. 2011. The long-term effects of water fl uoridation on the human skeleton. Journal of Dental Research 90(5): 683.
Rugg-Gunn, A.J., and L. Do. 2012. Effectiveness of water fl uoridation in caries prevention. Community Dentistry and Oral Epidemiology 40(suppl 2): 55–64.
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annexes. Geneva: WHO. http://apps.who.int/gb/ebwha/pdf_fi les/WHASSA_WHA60-Rec1/E/ cover-intro-60-en.pdf . Accessed 10 Dec 2012.
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World Health Organization (WHO). 2012. Oral health , Fact Sheet No. 318. Geneva: World Health Organization. http://www.who.int/mediacentre/factsheets/fs318/en/ . Accessed 30 Mar 2013.
5.11 Case 5: The Prohibition of Smoking in Public Places in Bulgaria
Silviya Aleksandrova-Yankulovska Faculty of Public Health, Department of Public Health Sciences Medical University of Pleven Pleven , Bulgaria e-mail: email@example.com
This case is presented for instructional purposes only. The ideas and opinions expressed are the author ’ s own. The case is not meant to refl ect the offi cial position , views , or policies of the editors , the editors ’ host institutions , or the author ’ s host institution .
Chronic noncommunicable diseases , including cardiovascular diseases, malignant neoplasms, and noninfectious pulmonary diseases, are a major cause of the global burden of disease in the European Region 3 (86 % of the 9.6 million deaths and 77 % of the 150.3 million disability-adjusted life years (DALYs) (Vassilevsky et al. 2009 ). Commonly associated risk factors include smoking , alcohol consumption, unhealthy diet, and low physical activity.
Tobacco smoking alone produces 12 % of the global disease burden in the European Region (ranges from 3 to 27 % for the individual countries) and it causes 2–21 % of all deaths. For Bulgaria, these rates are 13.5 % and 12.4 %, respectively (Vassilevsky et al. 2009 ). Annually, more than four billion people die worldwide from diseases related to tobacco products. By 2030, this number is expected to reach ten million, which will turn tobacco smoking into the biggest single cause of death (World Bank 1999 ).
Bulgaria is among the countries with the highest level of morbidity and mortality from cardiovascular diseases, especially cerebrovascular disease. Standardized death rates of all smoking-related causes of death for 2011 were estimated to be 318
3 As of 2015, the European Region includes 51 countries (see http://www.who.int/choice/demogra- phy/euro_region/en/ ).
per 100,000 people, whereas the average for the European Union (EU) 4 was 195 per 100,000 people. Standardized death rates of stroke in Bulgaria were about three times higher than the average level for the EU. Only Ukraine, Moldova, Kyrgyzstan, and Russia had higher rates (World Health Organization [WHO] 2012 ).
At the same time, Bulgaria is a leading country in cigarette use among Central and Eastern European countries (Ministry of Health, Bulgaria 2008 ). About 40 % of the population are smokers: 47 % of men and 33 % of women (Vassilevsky et al. 2010 ). Cigarettes smoked per person per year in Bulgaria (2793 cigarettes) is sig- nifi cantly higher than the average for the European Region (1681 cigarettes) (WHO 2012 ). Smoking among teenagers in Bulgaria is also among the highest in Europe—40 % of teenagers smoke (36 % of boys and 44 % of girls) (Tsolova et al. 2010 ). A 2011 survey found that Bulgaria was fourth out of 36 countries in teenage smokers (Hibell et al. 2012 ).
These data are alarming. But additional concern for public health is the effect of secondhand smoking. The risk of death from coronary heart disease increases 30 % from exposure to secondhand smoke (American Heart Association 2013 ). Secondhand smoke—“passive” smoking—increases a child’s risk of developing pneumonia, asthma, and other allergic conditions (Naydenov et al. 2007 ). A survey of countrywide integrated noncommunicable disease intervention (CINDI) programme- Bulgaria found more than 80 % of teenagers were exposed to passive smoking daily (20 % of teenagers were exposed for 1–2 h per day; 50 % were exposed for more than 2 h per day). Exposure was higher among girls than boys (43.1 % of boys and 56.7 % of girls were exposed to secondhand smoke for more than 2 h per day) (Tsolova et al. 2010 ).
As a member of the EU , Bulgaria has had to harmonize its legislation with European legislation. The fi rst smoke free legislation in Europe was adopted in March 2004 in Ireland (Howell 2004 ). Currently, all EU member countries have some form of regulation aimed at limiting exposure to secondhand smoke. However, the scope of these regulations differs widely within the EU (European Public Health Alliance 2012 ). First attempts to prohibit smoking in public places in Bulgaria date back to January 2005. Restaurants and other food and drink places were separated into zones for smokers and nonsmokers. The Bulgarian society also split into groups of supporters of the changes and opponents of smoking restrictions.
On November 7, 2005, Bulgaria ratifi ed the World Health Organization Framework Convention on Tobacco Control . Article 8 of the Convention stipulates that “effective legislative, executive, administrative and other measures, providing for protection from exposure to tobacco smoke in indoor workplaces, public trans- port, indoor public places and, as appropriate, other public places should be taken” (WHO 2003 ).
On May 17, 2012, the parliament voted to amend the Bulgarian Health Act pro- hibiting smoking in public places (Republic of Bulgaria Council of Ministers 2012 ). According to the new regulation , which took effect June 1, 2012, smoking was
4 As of 2013, the European Union consisted of 28 member countries (see http://europa.eu/about-eu/ countries/member-countries/ ).
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prohibited in all indoor public places and workplaces including stadiums, children playgrounds, kindergartens, and other schools . Still, Bulgarian society remained confl icted about the issue.
In November 2012, two independent members of the Bulgarian parliament raised the issue of business losses from the smoking ban . They claimed that 10,000 people lost jobs due to fewer patrons of food and drink establishments and pleaded for revi- sion of the law (Todorova 2012 ). Offi cial data about business losses were not pro- vided, and such surveys have not been done. Nevertheless, these claims increased public debate about the smoking bans . On December 10, 2012, the Bulgarian Hotel and Restaurant Association offi cially protested the law and insisted it be revised. The prime minister initially agreed that some revision could be possible but later supported the minister of health, who opposed changing the law. The minister of health pointed out that pitting business against health was unacceptable and, instead of discussing business losses, the government should be discussing the cost of treat- ing oncological and cardiovascular diseases (Dimitrova 2012 ). The minister of economy, energy, and tourism favored a more fl exible application of the law . Eventually, decision making was transferred to parliament’s Economic Committee with the idea that the ban on smoking could be abolished through the Law of Tourism, particularly if certain amendments were adopted to allow smoking in spe- cifi c areas of bars and restaurants. On December 18, 2012, the Economic Committee rejected any amendment to the law. Thus, despite the controversy and public debates, the law prohibiting smoking in public places has survived without change as of May 2013.
5.11.2 Case Description
The law prohibiting smoking in public places has been enacted. You are aware of the public debate and tension surrounding the issue. What would you, as a director of the regional health inspectorate, do to guarantee the implementation of the law in the region?
5.11.3 Discussion Questions
1. When is it acceptable to limit personal autonomy to benefi t of the health of others?
2. How should economic interests be weighed in public health decision making? Specifi cally, how should health care expenditures due to smoking-related dis- eases be weighed against economic losses incurred by the ban on smoking ?
3. Law is usually regarded as the strongest measure of public control. Is law the best approach for infl uencing health behavior in a society where citizens tradi- tionally feel no responsibility for their own health or the health of others?
4. What long-term effects could repealing or revising the smoking ban have on the public’s trust and support?
5. In future years, if a new government decides to revisit the law, what would you, as an expert in public health, advise the new minster of health? Who are the relevant stakeholders, and which of their values should the minister of health consider?
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American Heart Association. 2013. Heart disease and stroke statistics—2013 update. http://circ. ahajournals.org/content/127/1/e6.full.pdf+html . Accessed 7 June 2013.
Dimitrova, D. 2012. Smoking prohibition confronted two ministers—The Minister of Economics Dobrev and the Minister of Health Atanasova. http://dnes.dir.bg/news/zabrana-deljan- dobrevmerki-srestu-pusheneto-12592161 . Accessed 10 Dec 2012.
European Public Health Alliance. 2012. Updated European smoking bans: Evolution of the legis- lation . http://www.epha.org/a/1941 . Accessed 10 Dec 2012.
Hibell, B., U. Guttormsson, S. Ahlström, et al. 2012. The European school survey project on alco- hol and other drugs: The 2011 ESPAD report, substance use among students in 36 European countries. http://www.espad.org/Uploads/ESPAD_reports/2011/The_2011_ESPAD_Report_ FULL_2012_10_29.pdf . Accessed 10 Dec 2012.
Howell, F. 2004. Ireland’s workplaces, going smoke free. British Medical Journal 328(7444): 847–848.
Ministry of Health, Bulgaria. 2008. National health strategy: 2008–2013. State Gazette 107/16.12.2008.
Naydenov, K., T. Popov, D. Markov, and A. Melikov. 2007. The infl uence of smoking on allergy morbidity among children in Sofi a and Burgas at age 2–7 years. Modern Medicine 58(4): 13–20.
Republic of Bulgaria Council of Ministers. 2012. Bulgarian health act. State Gazette 70/10.08.2004 (effective 01.01.2005). Amended 17th May 2012. State Gazette 40/29.05.2012 (effective 01.06.2012 г.). http://lex.bg/laws/ldoc2135489147 . Accessed 1 Dec 2012.
Todorova, T. 2012. Parliamentarians require changing the prohibition of smoking. http://dnes.dir. bg/news/tutunopushene-merki-srestu-pusheneto-kiril-gumnerov-12413757 . Accessed 10 Dec 2012.
Tsolova, G., N. Vassilevsky, P. Dimitrov, and A. Manolova. 2010. Surveillance of risk factors for non-communicable diseases among children aged 14–18 years within the zones of CINDI programme-Bulgaria 2008. Bulgarian Journal of Public Health 2(3): 35–60.
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Vassilevsky, N., L. Ivanov, G. Tsolova, and P. Dimitrov. 2009. National behavior risk factors sur- vey among population aged 25–64, 2007. Bulgarian Journal of Public Health Supplement 1(3): 3–42.
Vassilevsky, N., G. Tsolova, P. Dimitrov, and A. Manolova. 2010. Surveillance of risk factors for non-communicable diseases among population aged 25–64 within the zones of CINDI pro- gramme- Bulgaria 2007. Bulgarian Journal of Public Health 2(3): 3–32.
World Bank. 1999. Curbing the epidemic: Governments and the economics of tobacco control. Development in practice. Washington, DC: World Bank. http://documents.worldbank.org/ curated/en/1999/05/437174/curbing-epidemic-governments-economics-tobacco-control . Accessed 7 June 2013.
World Health Organization (WHO). 2003. WHO framework convention on tobacco control. Geneva: World Health Organization. http://www.who.int/fctc/text_download/en/index.html . Accessed 7 June 2013.
World Health Organization (WHO). 2012. European health for all database. http://data.euro.who. int/hfadb . Accessed 15 Dec 2012.
Chapter 5: Chronic Disease Prevention and Health Promotion
5.3 Formal and Informal Health Workers
5.4 Governments (At Different Levels)
5.5 Corporate Entities
5.6 Case Studies
5.7 Case 1: Municipal Action on Food and Beverage Marketing to Youth
5.7.2 Case Description
5.7.3 Discussion Questions
5.8 Case 2: Obesity Prevention in Children: Media Campaigns, Stigma, and Ethics
5.8.2 Case Description
5.8.3 Discussion Questions
5.9 Case 3: Obesity Stigma in Vulnerable and Marginalized Groups
5.9.2 Case Description
5.9.3 Discussion Questions
5.10 Case 4: Water Fluoridation: The Example of Greece
5.10.2 Case Description
5.10.3 Discussion Questions
5.11 Case 5: The Prohibition of Smoking in Public Places in Bulgaria
5.11.2 Case Description
5.11.3 Discussion Questions