Monday, July 26, 2010

Smoking in Public v. NIP: An Illogical Analogy

Recently a DJ from an Orlando, FL radio station interviewed a midwife about nursing in public. The DJ would prefer that women not nurse in public, and his questions to the midwife were very anti-breastfeeding in nature. At one point he said something to the effect of, “well if women are allowed to breastfeed anywhere, then smokers should be allowed to smoke anywhere they want.”

Today's piece is a collaborative effort that seeks to demonstrate why smoking in public is not an appropriate analogy for nursing in public (N.I.P.). Please feel free to share it with anyone else who tries to compare the two. Thank you to the following bloggers for their help creating this resource:
Annie at PhD in Parenting wrote about individual rights and public health.
Dionna at Code Name: Mama compared legislation on both smoking and breastfeeding.
Paige at Baby Dust Diaries discussed the effect on bystanders of smoking versus breastfeeding.
Lauren at Hobo Mama gave suggestions on how to deal with either smoking in public or N.I.P.


Individual Rights and Public Health

We all pay for poor health decisions. Whether through private insurance or public healthcare, when other people make bad decisions about their health or when they do things that have a negative impact on the health of others, it costs us money. I reluctantly accept the idea that people have the right to make poor decisions about their own health and that our health care system (be that private insurance or public health care) should still take care of them. But, I also think that our governments and insurance companies have a role to play in promoting healthier alternatives, taxing bad choices, and protecting people from being directly affected by the poor health decisions of others.

Smoking is bad for you. Smoking around other people is bad for them. There are countless studies and stories that point out the negative health implications of tobacco smoke. According to the World Health Organization:
Tobacco is the second major cause of death in the world. It is currently responsible for the death of one in ten adults worldwide (about 5 million deaths each year). If current smoking patterns continue, it will cause some 10 million deaths each year by 2020. Half the people that smoke today -that is about 650 million people- will eventually be killed by tobacco.
In addition to direct exposure to cigarette smoke, secondhand smoke is a significant problem. The Society of Actuaries in the United States determined in its 2005 research report Economic Effects of Environmental Tobacco Smoke that exposure to secondhand smoke costs the United States about $10 billion annually (out of a total of $150 billion annually for all smoking related health costs). This amount has decreased by $5 billion in recent years due to a reduction in the percentage of smokers among the population and also a reduction in exposure to smoke, showing that efforts to promote public health in this regards are having some level of success.

Breastfeeding, on the other hand, is good for you. It is good for the mother and good for the child. According to the World Health Organization:
The protection, promotion and support of breastfeeding rank among the most effective interventions to improve child survival. It is estimated that high coverage of optimal breastfeeding practices could avert 13% of the 10.6 million deaths of children under five years occurring globally every year. Exclusive breastfeeding in the first six months of life is particularly beneficial, and infants who are not breastfed in the first month of life may be as much as 25 times more likely to die than infants who are exclusively breastfed.
An economic study by Melissa Bartick et al called The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis and published in the Pediatrics journal found that if 90% of US families could comply with medical recommendations to breastfeed exclusively for 6 months, the United States would save $13 billion per year. If women feel uncomfortable or are made to feel uncomfortable nursing in public, there is a greater chance that they will wean earlier and be unable to meet those targets. It is inconvenient to have to always find a private place or private way to nurse and I can understand how feeling that you need to do so would lead moms to switch to formula. In addition, in order to increase breastfeeding rates, we need more women to be breastfeeding in public and being open about doing so. Only when our society sees nursing as the normal way to feed a baby, will it become the default way of feeding a baby.

So from a public health perspective, in order to improve the health of our population and cut down on medical costs, we need to continue to tell people that smoking is bad for you and ensure that people are not exposed to second hand smoke against their will. We also need to promote breastfeeding and ensure that women are encouraged to breastfeed whenever and wherever they want. Also, from a humanitarian point of view, we need to protect people from having their health threatened by others and also protect their right to do what is best for their family's health.

Interestingly, one of the linkages between the tobacco issue and the infant feeding issue is that poverty is a significant factor in both. People who are poor are more likely to smoke and to spend a significant amount of their limited budget on tobacco. People who are poor are also more likely to formula feed, which can also be costly (although it is often subsidized for low income families). From a public health perspective, I think one of the priorities needs to be on ensuring that low income families have the resources that they need and the role models that they need to be able to breastfeed successfully and to give up tobacco successfully. A part of that, to me, means ensuring that women are not ridiculed for breastfeeding in public by some jerk who is blowing smoke in their faces.

Smoking v. Breastfeeding: The Law

Photo credit: stringberd
Both smoking and breastfeeding have been the subject of legislation on federal and state levels. But legislation on the two differs significantly: whereas smoking is legislated because it is hazardous to public (and individual) health, breastfeeding is legislated because of its great health benefits.

The Long History of Laws Against Smoking

There are records of laws restricting the growth, trade, and use of tobacco products in the United States and Europe from as early as the 1600’s. The General Court of Massachusetts Bay enacted one of the first laws banning smoking in public in 1632. The 1600’s also ushered in the first laws prohibiting minors from smoking.1

In the late 1800’s and early 1900’s, the prohibitionists (those who wanted to ban the production/consumption of alcohol) also targeted cigarettes. “Between 1895 and 1921, 14 states banned the sale of cigarettes. Even in the city of New York it was declared unlawful for women to smoke in public.” But partially due to a powerful tobacco lobby, and partially due to the lure of income from taxes on tobacco, the cigarette bans were soon repealed.2

In “1964, the Federal Trade Commission concluded that cigarette advertising was deceptive . . . and that advertisers had a responsibility to warn the public of the health hazards of cigarette smoking.” Thus the warning labels on tobacco packages were born, but not without a fight from the tobacco industry. Regardless, several years later the FTC reported that the warnings were futile, probably in part because of the massive advertising campaigns by tobacco companies: “cigarette advertisers [were] the single largest product advertisers on television.”3

The Federal Communications Commission required television and radio stations in 1967 to start airing information on the health hazards associated with smoking. And in 1970 President Nixon signed into law legislation that banned cigarette advertising completely on television and radio; the law went into effect on January 2, 1971.

Since that time, lawmakers at local, state, and national levels have enacted (and courts have upheld) a variety of laws and regulations limiting the reach of deadly secondhand smoke. Smoking has been banned in airports, courtrooms, restaurants, on city sidewalks, in jails and schools, cities can even refuse to hire people who smoke in their own homes.4 Our neighbor to the north, Canada, has been at the forefront of anti-smoking measures: public smoking is banned in offices, restaurants, and in some cities all indoor spaces.5

There is no constitutional right to smoke, but we do arguably have the right to breastfeed.

"The U.S. Supreme Court has held that "only personal rights that can be deemed 'fundamental' or 'implicit in the concept of ordered liberty' are included in the guarantee of personal liberty." These rights are related to an individual's bodily privacy and autonomy within the home. Proponents of smokers' rights often claim that smoking falls within the fundamental right to privacy, by arguing that the act of smoking is an individual and private act that government cannot invade. Courts consistently reject this argument.

The privacy interest protected by the U.S. Constitution includes only marriage, contraception, family relationships, and the rearing and educating of children."6 By that definition, it would appear that breastfeeding is a fundamental right. The U.S. Supreme Court has never had to answer this question, though.7

State and Federal Legislation Protects Breastfeeding

While the U.S. Supreme Court has never had to answer the question of whether we have a constitutional right to breastfeed our children, there are both federal and state laws in place to protect a mother and child's right to breastfeed and to nurse in public. There are basically two types of law in place: "(1) those which exclude breastfeeding from indecent exposure or other criminal laws; and (2) those which expressly state a mother may breastfeed in public. . . . The lack of a state law does not mean that it is illegal to breastfeed in public. If a state does not have a law addressing public breastfeeding, it may mean that a private person, such as a restaurant owner, may have the right to ask a breastfeeding mother to leave. States with laws that only exempt mothers from criminal prosecution[] also do not prevent a restaurant or store owner from asking a breastfeeding mother to leave or breastfeed in another area."8

In Canada, breastfeeding is protected as a fundamental right. The right to breastfeed anywhere, anytime is protected by the Canadian Charter of Rights and Freedoms.9

International Regulations on Breastmilk Substitutes

Not only is breastfeeding protected by law, but there are measures in place to regulate the companies that produce and market breastmilk substitutes (including formula). Because "[t]here are no benefits of breastfeeding[; t]here are risks of formula feeding," every member of the World Health Assembly has voted to adopt the World Health Organization's International Code of Marketing of Breast-milk Substitutes. As part of the World Health Assembly's plan to protect and encourage breastfeeding, the Code places restrictions on how and where companies can advertise infant formula and other foods and beverages. Among other things, the Code provides:

  • Article 4.2 requires "[i]nformational and educational materials . . . dealing with the feeding of infants" to include information on: "(a) the benefits and superiority of breast-feeding; (b) maternal nutrition, and the preparation for and maintenance of breast-feeding; (c) the negative effect on breast-feeding of introducing partial bottle-feeding; (d) the difficulty of reversing the decision not to breast-feed; and (e) where needed, the proper use of infant formula . . . . When such materials contain information about the use of infant formula, they should include the social and financial implications of its use; the health hazards of inappropriate foods or feeding methods; and, in particular, the health hazards of unnecessary or improper use of infant formula and other breast-milk substitutes. Such materials should not use any pictures or text which may idealize the use of breast-milk substitutes."
  • Article 5.1 prohibits advertising or other promotion of the products covered by the Code.
  • Article 5.2 prohibits distribution of product samples of items covered by the Code.
  • Article 5.3 prohibits point-of-sale advertising, product samples, or other promotions at the retail level (including special displays, coupons, special sales, etc) of items covered by the Code.
  • Articles 6 and 7 place similar restrictions on health care facilities and health care workers.
  • Article 9.2 sets certain standards for labeling products. Manufacturers must include: "(a) the words "Important Notice" or their equivalent; (b) a statement of the superiority of breastfeeding; (c) a statement that the product should be used only on the advice of a health worker as to the need for its use and the proper method of use; (d) instructions for appropriate preparation, and a warning against the health hazards of inappropriate preparation." Labels may not include "pictures of infants, nor should they have other pictures or text which may idealize the use of infant formula."

Smoking in public is not analogous to nursing in public.

Tobacco use has long been regulated and restricted to protect the health of the users and of those subjected to secondhand smoke. Conversely, governments have enacted laws in order to protect the rights of breastfeeding mothers and children. And, similar to tobacco products, breastmilk substitutes are regulated in order to protect consumers and encourage breastfeeding. To compare smoking in public to nursing in public completely misses an important point: the laws governing breastfeeding exist to protect mothers and children who are safeguarding their own health by breastfeeding. The laws governing tobacco use exist to protect against the dangerous health consequences that occur because of tobacco, both to tobacco users and to those around them.

The Effects on Bystanders: Secondhand Smoke v. Secondhand Breastfeeding

Secondhand Smoke

You are sitting in your local eatery and a person at the table next to you lights a cigarette. What's the big deal, right? This is a free country after all (assuming smoking is legal in said eatery). Is there a real, tangible risk to you?

According to the National Cancer Institute yes.

1. There are more than 4,000 chemicals found in that secondhand smoke wafting over to your table including:
  • arsenic (a heavy metal toxin)
  • benzene (a chemical found in gasoline)
  • beryllium (a toxic metal)
  • cadmium (a metal used in batteries)
  • chromium (a metallic element)
  • ethylene oxide (a chemical used to sterilize medical devices)
  • nickel (a metallic element)
  • polonium–210 (a chemical element that gives off radiation)
  • vinyl chloride (a toxic substance used in plastics manufacture)
2. There are immediate effects on your body due to your co-diner's decision to light a cigarette including;
  • Cough
  • Nausea
  • Headache
  • Eye irritation
  • Sore throat
  • Dizziness
  • Difficulty in breathing in those already suffering from asthma
Additionally, tobacco smoke exposure has immediate and substantial effects on blood vessels in a way that increases the risk of a heart attack, particularly in people already at risk.10 Exposure to tobacco smoke for 30 minutes significantly reduces coronary flow velocity reserve in healthy nonsmokers.11

3. There are long-term risks associated with secondhand smoke;
  • Approximately 3,000 lung cancer deaths occur each year among adult nonsmokers in the United States as a result of exposure to secondhand smoke.12
  • In the United States, secondhand smoke is thought to cause about 46,000 heart disease deaths each year.13
  • Secondhand smoke may increase the risk of breast cancer, nasal sinus cavity cancer, and nasopharyngeal cancer in adults, and leukemia, lymphoma, and brain tumors in children.14
  • Children exposed to secondhand smoke are at an increased risk of sudden infant death syndrome (SIDS), ear infections, colds, pneumonia, bronchitis, and more severe asthma.
4. Your Caesar salad will taste like smoke.

Secondhand Breastfeeding

You are sitting in your local eatery and a woman at the table next to you begins to nurse her child. Without a cover. What's the big deal, right? This is a free country after all. Is there a real, tangible risk to you?

In my opinion, yes there is a risk to you.

1. You run the risk of seeing a human female breast being used in a manner that is not sexual and not serving the purpose of selling a product. You might be forced to question the objectification of women in our culture.

2. You run the risk of seeing the natural and standard form of feeding an infant. You may have to feel strong emotions about your decisions (or someone close to you) to feed your child formula.

3. You may run the risk of having your young child ask "what is that lady doing?" and you just might have to explain the biological purpose of breasts. Perhaps you can talk about what makes mammals unique or how breastmilk contains very healthy protective ingredients for the baby (the opposite effect, in fact of the previous smoke rings).

4. You might have your own personal boundaries of decency crossed. You may be offended. You run the risk of being faced with respecting the diversity of thought in our culture and learning to practice tolerance.

4. However, in all but the most extreme and unusual cases, I can assure you your Caesar salad will not taste like breastmilk.

Suggestions on How to Deal with Smoking and Nursing in Public

14th December 1951:  A woman having a cigarette break by the service hatch in a New York bar. Original Publication: Picture Post - 5784 - New York - unpub.  (Photo by Raymond Kleboe/Picture Post/Getty Images)
1951 photo of a woman on a cigarette break
by Raymond Kleboe, Getty Images
When I was pregnant, I was fiercely protective of my unborn little one's health. I don't live with a smoker or have geographically close friends who smoke regularly, so I don't come across it that often. But when I traveled to be with my mother during a health crisis she was having in my third month of pregnancy, I had to walk the gauntlet of smokers lining the waiting area outside the airports.

What did I do? I took a deep breath before arriving near any smoker and held my breath as I passed, to the point that I could. When I had to stand outside waiting for a bus, I continually moved my position to be as far from smoke as I could.

What did I not do? I did not fake a cough or wave my hand in front of my face. I did not grimace at the smokers and point tellingly at my slightly protruding belly, reminding them that there were children present. I did not tell them that if they wanted to smoke, they should do so at home where it's decent, or that they should have planned their trips so that they smoked just before they left and just after they got back. I did not heckle them and threaten to call airport security on them.

I feel like there are a lot of people out there saying the sight of public breastfeeding offends them. And to those people I say, that's why you have a neck. That's why you have eyelids. That's why you have the right to go somewhere else or stay home.

In other words, we as citizens of this diverse planet have personal responsibility to deal with our own feelings and reactions to things that bother us but are perfectly legal. In a free society, I have the right to form my own opinions about smoking, about interracial partnerships, about homosexual partnerships, about children's presence in public, about breastfeeding in public or at all, about wearing low-cut tops or no tops at all (men in summer hereabouts), about being part of a religion or culture that requires dressing in a very distinct way, etc. (I hope it's clear I'm not listing things I'm against. I'm listing things some people are against.)

What I don't have the right to do is impinge on people exercising their legal rights to act as they see fit. I don't have the authority to hand a blazer to someone I think is too skimpily dressed and insist that person don it. I don't have the right to pull a cigarette from someone's mouth and extinguish it beneath my heel. I don't have the right to demand a couple remove themselves from my sight.

Granted, free speech does give me the right to be a jerk. It's not good manners, but I could certainly voice my opinions on everyone else's behavior and generally make everyone in earshot feel uncomfortable. But I don't have the right to coerce the people I'm targeting to abide by my opinions, or to call in authorities to enforce my opinions.

In short, people who are against breastfeeding in public should do what I do around smoking in public: Deal with it on a personal level.

If it bothers you, turn away. Leave the area.

Even better, educate yourself on why breastfeeding is important, and therefore why breastfeeding in public is important. Work through your own hang-ups about what you demand of nursing parents, and reconsider it from their point of view. (For instance, would you want to eat in a restroom or with a blanket over your head? Would you want to be told you had to stay home for a year or couldn't leave without a complicated preparation of sterilized feeding gear that must stay at a proper temperature?)

And even more so, meet people who breastfeed. Find out what it's like for them, and hear their stories.

This actually works for anything on the list of things that might offend you. The more you get to know the people who practice what bothers you, the more you realize: "Huh! They're humans, too."

In regard to smoking, I have done all of those things. I still don't agree that it's a good idea to smoke, but I know smokers I admire and like, and I know more now about the hold smoking's addiction can have on people. I also take steps to curb my exposure to smoke. Before indoor smoking bans were passed, I avoided restaurants that were too smoky for my taste; I've asked to change hotel rooms when I've been granted a smoking room inadvertently; and I will avoid standing near someone who is smoking. It's up to me to make myself comfortable. It is not up to me to make smokers bow to my every wish.

When other people are doing something that's perfectly legal and reasonable, even if I don't agree with it, I need to step aside and deal with my own objections. My objections do not trump their rights.

In the same way, my right to feed my baby anywhere I am allowed to be is legally protected, and no one's opinion is allowed to take that away from me.

P.S. This doesn't even get into the myriad reasons smoking is different from breastfeeding and the way public smoking impinges on my right to physical health (because other astute bloggers will be tackling those issues) or the fact that oftentimes now, I'll come across smokers breaking the law, smoking directly under No Smoking signs. In Washington State, it's now illegal to smoke within 25 feet of doorways, so that I should be able to wait for my bus outside the airport's sliding doors without being engulfed in a poisonous cloud.

1. Jane Lang McGrew, History of Tobacco Regulation (citations omitted)
2. History of Tobacco Regulation (citations omitted)
3. History of Tobacco Regulation (citations omitted)
4. Action on Smoking and Health
5. Global Anti-Smoking Efforts
6. Public Health Institute, There Is No Constitutional Right to Smoke (citations omitted, emphasis added)
7. Melissa R. Vance, Breastfeeding Legislation in the United States: A General Overview and Implications for Helping Mothers
8. Breastfeeding Legislation in the United States: A General Overview and Implications for Helping Mothers
9. For more information, visit INFACT Canada.
10. Barnoya J, Glantz SA (2005). "Cardiovascular effects of secondhand smoke: nearly as large as smoking." Circulation 111 (20): 2684–98.]
11. Otsuka R, Watanabe H, Hirata K, et al. (2001). "Acute effects of passive smoking on the coronary circulation in healthy young adults". JAMA 286 (4): 436–41.
12. National Cancer Institute. Cancer Progress Report 2003. Public Health Service, National Institutes of Health, U.S. Department of Health and Human Services, 2004.
13. California Environmental Protection Agency, Office of Environmental Health Hazard Assessment. Proposed Identification of Environmental Tobacco Smoke as a Toxic Air Contaminant: Part B Health Effects, 2005.
14. U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006.


What a thorough response! How sad that there is even one idiot in the world who wastes oxygen and anybody else's time on a comparison between smoking and breastfeeding...

While you make a ton of good points on all kinds of favorite 2 lines are in the risks related to your Cesar salad.

Post a Comment

Please read the comment policy before posting. In short, "We encourage thoughtful, mature debate on everything we post. It is our desire to host a thoughtful, encouraging community for breastfeeding parents and those who support us. If you find yourself disagreeing with most of the content here, there are many other websites/communities where you might feel more comfortable."
If your comment does not conform to the policy, it will be deleted without notice.
All comments will be held for moderation, we apologize for the delay.