Public Health Advocacy

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Public Health Advocacy


Causes of ill-health: the risk factor reduction!

• Smoking - education, cessation supports, etc

• Alcohol - education, sensible/safe limits, etc

• Exercise - education, advise, etc

• Nutrition – education, Diet, the pyramid, etc

• RTA’s - education, driving schools, speed limits

• Etc etc etc etc


Market justice orientation(1)

• Rugged individualism

• Self - determination

• Strong individual control/responsibility

• Limited individual obligation to the collective good

• Limited government involvement in social activity


Market justice orientation (2)

• People act in their own best interest

• Assume risks knowingly and voluntarily

• Biological predisposition to illness

• Personal responsibility

• Blame the victim


Blaming the victim

• Problems are as a result of unusual events/circumstances

• They are exceptional rather than universal

• Jogger - Central Park - New York

• Personal responsibility - the ENTIRE solution

• Victims are “others”



Advocacy is a catch-all word for the set of skills used to create a shift in public opinion and mobilise the necessary resources and forces to support an issue, policy or constituency.

Advocacy is not just about lobbying Advocacy can be part of your day job!



Refers to the process of overcoming major STRUCTURAL barriers as opposed to INDIVIDUAL barriers to Public Health goals.

Advocacy seeks to increase the power of people and groups and to make institutions more responsive to human needs.


Types of Barriers

Political philosophies that devalue health and quality of life at the expense of economic outcomes

Political or bureaucratic opposition or inertia to health promoting legislative provisions

Political or bureaucratic opposition to the participation of consumers in healthcare planning

Marketing of unsafe and unhealthy products


Targets of Advocacy

Policies and practices of Governments and Institutions

Government laws and regulations Commercial marketing practices of

industries Activities of counter health lobbying

groups

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Being an Advocate

Advocacy is an integral part of any prevention strategy

It is issue and policy orientated It is not primarily about changing

individuals behaviour

Upstream/downstream

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Key issues to consider• The use of evidence

• Using data to support argument

• Setting targets – short to long term

• Power assessment

• Tactics

• Continuous evaluation

• Media Advocacy

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Evidence is crucial

• Supported by systematic empirical evidence• Supported by cogent argument• Scale of likely health benefit• Likelihood that policy would bring benefits other than

health benefits• Fit with existing or proposed government policy• Possibility that the policy might do harm• Ease of implementation• Cost of implementation

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Data are importantstrong and credible data basegives a clear analysis of the issues

to be addressedbe user friendly with the data

Health policies can be made in the absence of evidence, or despite evidence

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“Targets”

Goal setting is criticalsense of direction, unifying theme,

end point long range - short termwhat steps are needed to achieve

each goalhelps long term thinking and focuses

on the real issues

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Advocacy can be threatening “If there is no struggle there is no

progress. Power concedes nothing without a demand.”

challenges staid notions, vested interests upstream forces might not like it

Advocacy requires assessment what about your own organisational health can I win, can we afford to lose assess assets and liabilities and plan

strategies building broad, cohesive coalitions

- resources, strengths and weaknesses.

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Professor Ivan Perry, UCC

Irish Indep 29 Oct, ’03

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The media connection

In our “mass-mediated” democracy public health battles are fought not only in the clinics and the courts, but also on the 10pm news, the front pages, financial section and even on 24 hour all talk radio

The mass media constitute an important part of the environment in which the selection, presentation, definition and discussion of public issues occur

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Media advocacy

Seeks to influence the selection of topics by the mass media and shape the debate about these topics

Ensures that the story is told from a public health perspective

If you don’t exist in the media, for all practical purposes you don’t exist

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Understanding media advocacy More an art than a science

Improves with practice understand the needs of journalists set media objectives that relate to your

goals be on the alert for stories that help your

issue Never do anything that would

compromise your credibility

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Case study

Smoke-free Irish Workplaces, Including Bars.

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Key issues• Smoke-free workplaces introduced 29th March 2004

• Campaign did not start on the 28th March 2004

• Capacity building for years

• Part of a comprehensive tobacco control package – – price, advertising, sales to children, tar and nicotine levels etc

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The 70s

• Active smoking harmful

• Smokers’ rights universal

• Environmental tobacco smoke (ETS), passive smoking, involuntary smoking – what is that?

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Environmental tobacco smoke- is it bad for you?• For the moment most, but

not all, the pressure to have the right to breathe smoke-free air must be based on aesthetic considerations rather than on known serious risks to health.

Editorial, BMJ, 1976.

Excuse me, Do you mind if I smoke?

No, only if you don’t mind if I fart

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The 80s

• Increasing awareness of tobacco control issues

• Advertising bans

• Health warnings on packs

• Sales to children

• ETS – could it be bad for you?

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Passive smoking – the evidence emerges

• 1982 - US Surgeon General. The health consequences of smoking: cancer.

– Reviewed 3 studies showing an increased risk of lung cancer in non-smoking women whose husbands smoked

– Conclusion - cautious

• 1986 - US Surgeon General. The health consequences of involuntary smoking.

– Reviewed 13 spousal studies

– Conclusion: Involuntary smoking is a cause of disease including lung cancer, in healthy non-smokers.

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• 1986 - US National Research Council. Environmental tobacco smoke: Measuring exposures and assessing health effects.

• 1986 - IARC. IARC monographs on the evaluation of of the carcinogenic risk of chemicals to humans: tobacco smoking.

• 1986 - UK DHSS. Fourth report of the independent scientific committee on smoking and health.

• 1986 - Australian NHMRC. Effects of passive smoking on health.

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The 90s• Increasing awareness of

adverse health effects of ETS

– Irrevocably changed balance of smokers’ rights versus non smokers’ rights

• Irish Legislation• Restrict consumption (non

smoking areas) in specified locationse.g. Public offices, schools, colleges, cinemas, theatres, taxis, health and child care facilities, “restaurants”

• Voluntary code for the workplace

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Further “action”

– Minister for Health Consultative Committee 1992• Employers/unions/officials

– Recommended Voluntary Code of Practice on Smoking in the Workplace

– Employers to be proactive– Published “Clean Air at Work”– Circulate it– Review in 12 months

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ASH Ireland• 1991-1992 – Irish Heart Foundation +Irish Cancer Society

discussion re tobacco control

• 1992 - ASH Ireland founded by IHF+ICS

• Admin Support (Ms Valerie Coghlan)• PR Support

• Advocacy for tobacco control– Media driven!

• Mission - ASH Ireland, in pursuance of a tobacco free society, aims to reduce the toll of disease, disability and death caused by tobacco use.

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1994 - Review of the effectiveness of the 1992 voluntary code

• Restructured Consultative Committee– Only 1,200 copies sent to employers– Poor awareness of the Code

• Recommend continue voluntary code as against legislation

• Further review in 2 years• Revised code of practice • Endorsed by employers/trade unions• Circulate widely

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Further action• 1994 Health Strategy: Shaping a healthier future

– Extend environmental controls over tobacco, especially those in the workplace

• 1995 Regulations extend places where smoking banned– Child care facilities /All Health care premises– Bingo/Bridge/Snooker – Public areas in retail financial agencies, Banks etc– Public areas in hairdressing salons/barber shops– Taxis and hackneys, aircraft/ferries– 50% of seating in restaurantWorkplaces still excluded!

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…..As the evidence grew …the lobbying continued

• Issue focused as a health and safety issue• For all workplaces, including bars• Reach for the unreachable ? – deliberate strategy

• Not a consumer protection issue• Not a smoking reduction issue

• Politicians, public servants, trade unions targeted• Constant media linkage• International Research highlighted• International developments highlighted

– California, Canada, Australia, Finland

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Outcome…..end of the 90s/start of the 2000

Parliamentary Enquiry 1999• Joint Oireachtas (Parliament)

Committee on Health and Children (multi- party)

• Heard evidence from wide range of groups: – Minister’s officials– European Commissioner– Public servants– NGOs– Tobacco Industry– Academics

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Parliamentary Enquiry 1999

• Rejected tobacco industry insistence that ETS not harmful to non smokers

• Recommended new national anti-smoking strategy, many far-reaching initiatives, including– Restrictions on workplace, including bars– New unit to deal solely with tobacco control issues

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• 2000 DOHC Report : Towards a tobacco free society– Recommended ban on smoking in workplaces, except bars– Establish Office of Tobacco Control (NB)

• 2000 June– Complete ban on tobacco advertising in print media came into

force• 2001 Joint Committee on Health and Children

– Reaffirms recommendation on ban on smoking in all workplaces• 2001 – The Public Health (Tobacco) Bill 2001,

– The provisions in the Bill allow the Minister for Health and Children to prohibit smoking in all places, including the workplace, by way of regulation.

– Allows the establishment of the Office of Tobacco Control

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Next steps…………build capacity

• Feb 02 –OTC Conference – specifically on passive smoke

– International Experts/ICTU/HSA involved– James Repace “……. Based on this study and my

own studies of the effects of ETS on such workers in Hong Kong and Boston, I would estimate that approximately 150 bar workers a year in Ireland will die from ill health caused by ETS."

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Pressure from the lobbying front……………

• ASH Ireland concerned about silence from Health and Safety Authority

• ASH Ireland sends a series of FOI requests to Health and Safety Authority

• Evidence emerges that their Board (IBEC/ICTU reps) not very proactive on the issue

• Direct approach to Minister in charge, Mr. Tom Kitt TD

• He asks HSA to examine the possibility of banning smoking in workplace

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How extensive should workplace restrictions be?

• Health and Safety Authority (HSA) & OTC jointly commissioned independent scientists to review evidence on ETS.

• Chair Dr Shane Allwright, • Terms of reference

“To identify and report on the degree of consensus that exists among leading scientific authorities on the question of the hazard and risk posed by environmental tobacco smoke to human health in the workplace.”

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…………….. and

• June 2002 – IARC has concluded that involuntary smoking is carcinogenic to humans (Group 1).

• Nov 02 – Minister suggestions– Complete ban in workplaces/restaurants– Partial ban in pubs – when food served and to have specific

no-smoking areas

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and as a result…………………….

• Ridiculed by Vintners

• Bar workers trade unions furious!

• Opposition politicians go on the attack!

• NGO Community lobby harder!!And then……………………..

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Authors concluded

• ETS cause heart disease cancer and respiratory probs

• Employees need to be protected

•Ventilation is ineffective

•Legislative measures are required

30 th January 2003

Allwright Report

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What happened next……….

• Publicans condemned the Government's decision to announce a ban on smoking in all licensed premises from January 1st next.

• Unnecessary, unworkable, unenforceable

• 15 months of “fun”

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Anti-ban side• Bar owners – economic impact, compromise

proposals, ventilation• Employers organisation supported bar owners• Some senior Ministers tried to jump ship• Enstrom Kabatt study• Death of bar worker in New York• Tobacco industry intervention (minimal)• ++++

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Proposed Ban on Smoking in the WorkplaceDraft Tri-partite Position Statement (11th July 2003)

(and a cast of thousands!)

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Public Health Advocacy Campaign

If you don’t exist in the media, for all practical purposes you don’t exist

• Letters to the national papers

• National Radio

• Local Radio

• Sunday features

• Chat shows

• TV shows

• Etc etc

Anytime, anyplace, anywhere!

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Simple messages repeated +++• Health and Safety issue• ETS is a serious cause of ill health• All workers deserve protection• Ventilation does not work• Separate areas do not work• Smokers are reasonable• Provide assistance to help them quit if they wish to

• Not a consumer protection issue• Not a smoking cessation issue• Not a tobacco control issue

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OFFICE OF TOBACCO CONTROL

• Montague Communications have won a PR Excellence Award for our management of the Office of Tobacco Control's campaign to build public compliance with the smoke-free workplace legislation

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Irish Times, Oct 16, ’03

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Other helpers………• Trade union Movement• Health care professionals• Boston experience as against California• Minister for Health and Children visits New York• Political opposition previously tied in -‘silenced’• DOHC “Every cigarette is doing you damage” campaign• DOHC “Smoker’s quit line”• CMO Support• International tobacco control community• ++++++++++…………………………..

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Irish Times

27 Sept, ’03

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March 29th 2004

The big day………………………what would happen??

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The Broadsheets Editorials

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The Red Tops Editorials

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Implementation of ban• Resounding and astonishing success - so far• Almost universal compliance, rural and urban• Self enforcing + Enforcement Officers• Media support

– Supportive editorials in both broadsheets and tabloids

• Bar owners –some angry, some not• Smokers

– Some angry– Opportunity to give up– Smoking less

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High degree of public support• 93% think the law was a good idea, including

80% of smokers

• 96% of people feel the law is successful, including 89% of smokers

• 98% believe that workplaces are healthier, including 94% of smokers

• RTE New Year Poll 2004 – How was it for you?– Smoke-free law voted the no 1 high of 2004

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Compliance is very high

• 93% of all hospitality premises inspected were smoke free

• 92% of non hospitality sector were smoke free

• 96% of all indoor workers report working in smoke-free areas since the ban

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Why so successful?• Check back with New York and Boston • Keep the message simple !• 15th Month media debate • Most smokers don’t want to be smokers• Opportunity to quit• Most smokers are reasonable• Silent majority non-smokers, biding time• Onus on employer/owner to enforce• Most people are law abiding

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Understanding advocacy

Governments/Institutions adopt policies in a climate of public readiness

Public health advocates need to shift public opinion in the right direction

Political action becomes compellingPolitical inaction becomes a liability

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Ireland Smokefree!

Documents

Public Health Advocacy