Case Studies in Nanny State Name-Calling: What Can We Learn?

public health xxx (2015) 1e9

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Public Health

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Original Research Case studies in nanny state name-calling: what can we learn?

R.S. Magnusson

Sydney Law School, University of Sydney, Australia article info abstract

Article history: The ‘nanny state’ has become a popular metaphor in debates about public health regula- Received 9 September 2014 tion. It fulfils a particular role in that debate: to caution government against taking action. Received in revised form This paper presents case studies of nanny state criticisms, using them to identify a series 28 April 2015 of contextual features that may assist in better understanding, evaluating and where Accepted 28 April 2015 appropriate, resisting the rhetorical force of nanny state criticisms. The case studies pre- Available online xxx sented include Rush Limbaugh's reactions to Michelle Obama's efforts to encourage American food companies to market healthier food to children; Christopher Hitchens' Keywords: critique of New York City Mayor Michael Bloomberg's public health policies; and the re- Non-communicable diseases (NCDs) action of neoliberal think tanks to Australia's plain tobacco packaging legislation. These Politics case studies do not provide a basis for making generalisations about the practice of ‘nanny Regulation state name-calling’. Nor do they preclude debate about the appropriate limits of govern- Public health law ment action. However, in appropriate cases they may assist policy-makers and public Personalresponsibility health advocates to contest the framing of public health interventions as unwarranted Nanny state incursions into the private lives of individuals. One important lesson from these case studies is that the principal concern of nanny state critics is not loss of freedom as such, but the role of the state. The nanny state critique is ultimately a call for the state to be agnostic about the health of citizens, allowing market forces to dominate. Although the nanny state critique is not new, it is a significant challenge to government efforts to address lifestyle-influenced risk factors for non-communicable diseases, including tobacco use, harmful use of alcohol, and unhealthy diet. © 2015 The Author. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

individual autonomy are prized values. The metaphor has Introduction force because it associates government action with a fussing, over-bearing nanny who intrudes into the private lives of ’ The ‘nanny state has become a popular metaphor in debates citizens and treats them as infants who cannot be trusted to about public health regulation. Associating a new law or pol- make their own decisions. ’ icy with ‘nanny is a stinging criticism, especially in western, While reasonable people might disagree about the appro- liberal, democracies where liberty, independence and priate limits of government action to protect the public's

E-mail address: [email protected]. http://dx.doi.org/10.1016/j.puhe.2015.04.023 0033-3506/© 2015 The Author. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: Magnusson RS, Case studies in nanny state name-calling: what can we learn?, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.04.023 2 public health xxx (2015) 1e9

health, it is clear that the nanny state critique fulfils a exceeded 23 in a thousand over a five year period. Local Boards particular role in public debate: its role is to caution govern- were authorised to regulate drainage, the water supply, ment against taking action. As discussed below, by aligning sewerage, slaughterhouses, the removal of rubbish and filth personal autonomy and authentic individualism with market from streets, and burials.6 From the beginning, the Act was forces and the absence of regulatory controls over the activ- resisted by landowners, who appealed to the primacy of pri- ities of tobacco, alcohol and unhealthy food businesses, the vate property and freedom. In 1854, when Parliament refused nanny state critique has the potential to undermine public to renew the Act beyond its initial term, The Times celebrated support for important public health reforms. Although it is in an editorial which read ‘[w]e prefer to take our chance with possible for governments to trample on the dignity and civil cholera and the rest than be bullied into health’.6 liberties of individuals in pursuit of better health outcomes, Earlier, in 1847, when the House of Commons debated the most nanny state criticisms offer no hint of a workable test for Public Health Act, known at that time as the Health of Towns Bill, identifying when public health measures ought to give way to an opposition member, Mr Muntz, opposed the bill in terms self-governance. that sound very familiar over 160 years later. ‘There was a This paper presents some case studies of nanny state mania now for sanitary measures’, Muntz observed. ‘In fact, criticisms, using them to identify a series of contextual fea- there was an insanity in sanity’. The bill, which appointed tures that may assist in better understanding, evaluating and inspectors with powers to regulate unsanitary premises ‘was a where appropriate, resisting the rhetorical force of nanny very expensive principle, a very unsafe principle, and a very state metaphors. The case studies presented here do not unsound principle. The people were clever enough to manage their provide a basis for making generalisations about the practice own affairs’.7 of ‘nanny state name-calling’. However, in appropriate cases they may assist policy-makers and public health advocates to contest the framing of public health interventions as unwar- ‘You are too stupid’: Rush Limbaugh, and the free ranted incursions into the private lives of individuals. market The nanny state critique is not new. However, it has become increasingly important due to the nature of modern What makes the nanny state a compelling and contagious health risks. Global death and disability outside Sub-Saharan metaphor? What makes it ‘sticky’? Africa are overwhelmingly caused by lifestyle-influenced, A clue comes from Rush Limbaugh, a right-wing American non-communicable diseases (NCDs), particularly heart dis- ‘radio shock jock’ whose public pronouncements include ease and stroke, cancers, chronic lung diseases and diabetes.1 repeatedly calling a student at the Georgetown University Law The cluster of modifiable risk factors that contribute to Center a ‘slut’ and a ‘prostitute’ for expressing the view, disability and premature mortality from these diseases before a Congressional committee, that contraception should include tobacco use, harmful use of alcohol, obesity, lack of be covered under President Obama's national health insur- physical activity, and unhealthy diet including excess salt, ance plan.8 In September 2013, Michelle Obama became the sugar and saturated fat.2 These risk factors are not only a target for Limbaugh when she convened a summit at the reflection of the accumulation of lifestyle preferences and White House on food marketing to children, and challenged choices, but are simultaneously sites for consumer trans- American food companies to use their expertise to market actions and fierce competition between tobacco, alcohol and healthier food to children.9 food companies. The nanny state is not, therefore, simply a ‘Let me tell you the truth of the matter’, said Limbaugh. philosophical critique, but a weapon that assists tobacco, ‘This is none of her business. The free market takes care of alcohol and processed food businesses, and their allies, to this stuff.’10 resist regulatory threats. ‘This is how the slow creep happens’, he explained. ‘The good intentions of a supposedly nice woman who's a great mother with a great garden who really cares about people. At ‘The people were clever enough to manage their the root of it is her belief that you are too stupid to know own affairs’ what's good to eat and drink and what isn't. You are too stupid to know how to best take care of and look out for yourself. You According to Daube, Stafford and Bond,3 the term ‘nanny are too stupid to do what they want you to do on your own, state’ was invented in 1965 by a former British Minister for and because you're too stupid or because you are too resistant, Health, Ian McLeod, who chain-smoked his way through a they are going to use force.’10 press conference in which he acknowledged an association ‘We believe in the free market’, explained Limbaugh. ‘We between smoking and cancer.4 The practice of nanny state believe in life. We believe in people having choice, to live their name-calling, however, is as old as modern public health it- life as they choose. Coca-Cola, Twinkies, don't kill anybody. self. Public health action has frequently been controversial, It's none of our business.’ whether directed at contagious diseases and toxic pollution, Clearly, Michelle Obama's health promotion activities were or at behavioural health risks and NCDs. not a threat to Limbaugh's personal autonomy or freedom, nor The foundation stone of modern public health, Britain's to anyone else's. Nevertheless, by using her position as the 1848 Public Health Act, provides a good illustration.5 This Act First Lady to attempt to influence business, Michelle Obama tackled the leading causes of death of its time, appointing a was tampering with a belief held sacred and precious by General Board of Health for a trial period of five years, which neoliberals around the world. The state should be agnostic had power to set up local Boards in areas where the death rate about what citizens choose to eat and drink, and whether or

not they smoke, deferring instead to the wisdom of the current of feeling in the community. When the Australian market. Broadcasting Commission ran a story on the removal of the With government sidelined, private enterprise, and mem- website for the Star Rating System, on orders of the Assistant bers of civil society, can compete in the marketplace of ideas, Health Minister, it sparked vigorous debate online. ‘Amarak’ allowing citizens to choose products and lifestyles to match led the charge: ‘why should Tony Abbott [Australia's Prime the level of health that they want. ‘It's none of her business the Minister] be held responsible for your waistline? Surely people way food's marketed and sold,’ explains Limbaugh. ‘The free don't need warnings to know they are eating junk food? market takes care of this stuff’. Whatever happened to personal responsibility?’ What is interesting about Limbaugh's philosophy is less the ‘APM’ agreed. ‘Most Australians know full well what they stripped-back, minimalist role he evidently sees for the are eating and choose to be gluttons. More information from state,11 and more the fact that any challenge to the primacy of the nanny state won't make any difference. We are not slaves the market is framed as an insult to the intelligence of the to advertising for what we stuff in our gobs. It's pathetic!’15 individual: as something worth getting angry about. In a PW wasn't so sure. ‘Hmm, so advertising makes people do similar vein, in an article entitled ‘The war on fat: is the size of (or eat) whatever the evil corporation paying for the ad wants your butt the government's business?’,12 Joseph Sullum them to do?’ Well yes it does, in fact. If it didn't, there would be frames government actions to reduce population weight gain no such thing as advertising.’15 as anti-capitalist manipulation. ‘[T]he war on fat … reflects an anti-capitalist perspective that views people as helpless automatons manipulated into consuming whatever big corpo- What can we learn? rations choose to produce. The anti-fat crusaders want to manipulate us, too, but for our own good’.12 With the exception of smoke-free laws, and notwithstanding There are some important lessons here for public health the unsuccessful efforts of New York City's Health Depart- campaigners. Nanny state theorists have become experts in ment to impose a maximum serving size of 16 fluid ounces framing health interventions as insults to the dignity and in- (473 ml) for sugar-sweetened drinks,16 the popularity of the telligence of ordinary people. This helps to explain why the nanny state metaphor does not demonstrate that personal nanny state critique applies not only to interventions that liberty and freedom are being seriously threatened by gov- truly restrict the freedom of individuals (e.g. smoke-free laws), ernment. The deeper source of discontent lies is the way in but to non-coercive, information-based interventions e like which policy interventions contest assumptions about the health warnings, and clearer nutrition labelling e that are individual as wholly self-sufficient, independent, savvy, and aligned with the values of consumerism: informed choices immune from corporate manipulation. No one wants to be and personal responsibility. told that the government believes they are too stupid to decide Australia's experience with front of pack nutrition labelling what food to buy, or that they are ‘helpless automatons provides a recent example of these processes at work. During manipulated into consuming whatever big corporations 2012e2013, the Department of Health oversaw the develop- choose to produce’.12 Ironically, it is this same, treasured ment of an interpretive, front-of-pack labelling system that sense of self-sufficiency that makes nanny state name-calling aims to assist people to make healthier choices. The scheme a powerful ally as the tobacco, alcohol and processed food includes an evaluation of the overall nutritional quality of the industries seek to maintain market share and their influence food by means of monochrome stars displayed on the front of over consumer purchasing patterns. the pack. It also includes an energy declaration for the food There are many examples of public health interventions per 100 g or 100 ml, and nutrient content declarations showing that seek to influence or re-shape the informational environ- grams of saturated fat and sugar, and milligrams of sodium ment.17 These include laws preventing misleading and per 100 g or 100 ml of the food.13 deceptive conduct, front-of-pack food labelling, health warn- In February 2014, a federal Parliamentarian, Ewen Jones ings, and advertising controls, including Australia's tobacco MP, called for the system to be scrapped. ‘It's tough enough plain packaging legislation.18 Interventions such as these may being a fat guy without the Government telling you you're a fat be particularly susceptible to nanny state criticisms precisely guy as well and [that] everything you eat is wrong,’ he said.14 ‘I because their role is to encourage healthier decisions through am obese and I carry a lot of weight … I'm not fat because I'm better information, or by constraining the influence of stupid, I'm fat because I eat too much.’14 ‘If I do go through the advertising. For nanny state theorists, all such interventions drive through at Maccas … it's because I need a guilty treat. It's are insulting and demeaning, and can be powerfully framed as not the Government's fault that I'm fat, it's my fault and I live evidence that government thinks you are too stupid to know how with the consequences.’14 Although Mr Jones conceded that best to take care of and look out for yourself. government does have a role in health, that role does not extend to ‘putting great big stickers on my food’.14 The suggestion that interpretive food labelling should be Christopher Hitchens: ‘I decided all of life is a abandoned because it might make people feel bad when they wager’ fail to exercise personal responsibility is an interesting perspective that seems rather at odds with the goal that In November 2003, the expatriate British journalist and polit- nanny state theorists claim to support: encouraging people to ical commentator Christopher Hitchens went on a crime spree take greater personal responsibility for their lives and de- in New York City. Fed up with the ‘capricious’ and ‘petty’ laws cisions. Nevertheless, Jones' comments may tap a wider of Michael Bloomberg, the New York Mayor, he set out to

Please cite this article in press as: Magnusson RS, Case studies in nanny state name-calling: what can we learn?, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.04.023 4 public health xxx (2015) 1e9 break as many as he could, treating readers of Vanity Fair What can we learn? magazine to a blow-by-blow account of his adventures.19 During the course of the day, Hitchens sat on an upturned Hitchens' New York City crime spree occurred when Hitchens milk crate, he took his feet off the pedals while riding a bicycle, was at the height of his powers: flamboyant, provocative, and engaged in some loitering by sitting down on the subway entertaining, but most importantly, not dying from diseases steps. After securing the permission of other patrons, Hitch- the city's public health policies were intended to prevent. It is ens smoked a cigarette in a restaurant, denouncing the possible, of course, that a smoker might castigate tobacco smoke-free laws that e in his words e have ‘deprived control laws between breaths from their portable oxygen restaurant owners of the choice of allowing their customers to canister, or that a diabetic might rail against ‘nanny state smoke’. Michael Bloomberg e mayor of New York City for 12 nutrition labels’ and totalitarian bans on junk food advertising years until January 2014 e comes in for ceaseless abuse. ‘Who as they learn to walk again after the removal of their toes. knows what goes on in the tiny, constipated chambers of his However, I am not aware of any such cases. mind?’ Hitchens wonders. The irony of prevention is that when it works, nothing Hitchens' piece in Vanity Fair was published at a time happens e literally. People live long and productive lives, and when Hitchens' editor, Graydon Carter, was engaged in a it is easy to overlook the contribution that well-designed running battle with the New York City Health Department public policies have made to their life opportunities, over enforcement of the city's smoke-free laws.20,21 Hitchens achievements, and personal happiness. later revealed that a member of Carter's staff had reported When people do get sick from preventable NCDs, their ill- Carter to the Health Department for having a cigarette in his nesses tend to be lived out in the private realm. After all, these office with Hitchens.22 Vanity Fair's offices are non-smoking illnesses are so common they are hardly newsworthy. Occa- areas, and Carter was fined. Not long after, Carter went on sionally, a public figure comes forward to warn others, or to holidays, but Conde Nast, publisher of Vanity Fair, was fined express regret. For example, in 2004, Jim Bacon, a former for the empty ashtray left behind in Carter's office.21 Premier of the State of Tasmania (1998e2004), was diagnosed Reflecting on the laws that eliminated smoking carriages on with lung cancer. He told the media, ‘I have been a smoker for trains, Hitchens remembers thinking: ‘now we've crossed a 35 years … I have been an idiot. I have not listened’.30 small but important line. It's the difference between pro- Yet it is precisely at the time when illness strikes e when it tecting non-smokers and state-sponsored behaviour modifi- will usually be grotesquely inappropriate to highlight an in- cation for smokers’.22 dividual's misfortunes for the purposes of public policy debate Second-hand smoke laws are an odd rallying post for cries e that one truly catches a glimpse of the public interest that of nanny state oppression. Tobacco causes the death of public health policies are intended to protect. Inevitably, the around six million people each year, including over 600,000 public's interest becomes personalised in the suffering and non-smokers who are exposed to second-hand tobacco experience of each individual. Not surprisingly, that experi- smoke.2 Smoke-free laws protect non-smokers from harms ence changes perspectives e even those of nanny state critics. they have not consented to while exercising their own Regrettably, however, the value of this is usually lost. The freedom of movement in bars, restaurants, and other public injury caused to the individual cannot be healed, and public spaces. In addition, they are responsible for reintroducing a health laws and policies, by and large, are not written by the public good entirely unknown to previous generations: fresh dying. air. Smoke-free laws not only dramatically reduce hospital Although regret is a major theme for people who are living admissions from heart attacks triggered by tobacco smoke,23 with, or dying from, preventable illnesses, it is conspicuously they also reduce rates of premature birth, and paediatric absent from nanny state discourse. Fong, Hammond and hospital admissions for asthma.24 Hitchens' resistance to colleagues found that the overwhelming majority (around smoke-free laws in public places is less consistent with lib- 90%) of 8000 smokers surveyed in the United States, the ertarianism, and more consistent with the view that non- United Kingdom, Canada, and Australia, regretted starting to smokers should be obliged to put their health at risk to smoke and would not start if they had their time again.31 Far accommodate smokers. from being ‘carefully calculating utility maximizers’, smokers The Bloomberg administration's tobacco control measures regret their smoking, regardless of the differences in tobacco were brilliantly successful. The Health Department's strategy policies between these countries. The authors report the included raising tobacco taxes, comprehensive smoke-free following portrait of the predictors of regret: legislation, better access to smoking cessation medications, and mass marketing campaigns.25 In 2013, New York City Regretful smokers are those who believe themselves to be raised the minimum age for purchasing tobacco products to addicted. These regretful smokers report that smoking has low- 21 years, including for e-cigarettes.25 Between 2002 and 2010, ered their quality of life and will continue to do so in the future. smoking prevalence in New York City fell from 21.5% to 14%, Although they are more likely to perceive that there are benefits of in contrast with a fall from 22.3% to 19.3% in the US as a quitting, they have tried to quit multiple times, they have failed, whole.26 Between 2002 and 2012, the adult smoking rate in and now they fear the future consequences to their health. As one New York City fell by 28%; among youth smokers, it fell by 52% reflection of this concern over the impact of smoking on their (2001e2011).25 Many of those who quit will now live longer and health and quality of life, regretful smokers smoke light ciga- healthier lives, thanks to Bloomberg's ‘nanny state’ e a model rettes, which are positioned by the tobacco industry to appeal to e for city and municipal governments worldwide.27 29 these concerns. They know they spend too much money on

smoking, and they perceive not only that there are fewer places been ‘in denial’ for some time, knowingly burning the candle where one can smoke these days but that their significant others at both ends … .[F]or precisely that reason, I can't see myself believe they should not be smoking.31 smiting my brow with shock or hear myself whining about how it's all so unfair … . Instead, I am badly oppressed by a If it is reasonable for us to regard smokers as having over- gnawing sense of waste. I had real plans for my next decade and felt valued the front-end benefits of smoking relative to its more I'd worked hard enough to earn it. Will I really not live to see my remote health costs (as they themselves apparently do), then children married?’35 there may be a legitimate space for policies that not only protect non-smokers, but support the choices that, upon reflection, the smoker would endorse and wish to make.32 Plain tobacco packaging: nanny runs wild? While this argument may have its limits, public health advocates should not assume that those who smoke, drink to Prior to Australia's 2013 federal election, a conservative excess or have an unhealthy diet are necessarily antagonistic columnist for Rupert Murdoch's favoured national broad- to public policies and laws that would make healthy choices sheet, The Australian, delivered a prescription for victory in a easier, and unhealthy choices more difficult. feature piece written for a right-leaning think tank, the Insti- When Hitchens was diagnosed with inoperable cancer of tute of Public Affairs (IPA). Titled ‘End the nanny state to win’, the oesophagus in July 2010, he continued to write and to Christian Kerr castigated the liberal-national coalition for speak to the media about his illness. His diagnosis created a being too meek and silent during its time in opposition about rare opportunity for a seasoned nanny state theorist to re- the rise of the nanny state. He offered as examples the tax consider that critique in light of the assumption e appar- increases on sweet alcoholic drinks (‘alcopops’), and the plain ently shared by Hitchens himself e that his death was pre- tobacco packaging legislation introduced by the Labour gov- mature, and probably hastened by his smoking and drinking. ernment.18 Kerr pointed to IPA-funded polling which asserted ‘I've come by this particular tumour honestly’, Hitchens that ‘66 per cent do not believe that plain [tobacco] packaging told Anderson Cooper on CNN in August 2010. ‘If you smoke, will be effective in reducing consumption of cigarettes’.36 which I did for many years very heavily with occasional Australia's Tobacco Plain Packaging Act 2011 prescribes the interruption, and if you use alcohol, you make yourself a colour, shape and appearance of tobacco packages, including candidate for it in your sixties.’ ‘I might as well say to anyone the labelling of tobacco brands and variants, and suppresses who might be watching e if you can hold it down on the the use of trademarks and other brand characteristics.18,37 smokes and the cocktails you may be well advised to do so’.33 The Act contains a variety of offences for manufacturing, Cooper responded ‘That's probably the subtlest anti- retailing and for purchasing non-complying tobacco products, smoking message I've ever heard’.33 with the exception of purchase for personal use. ‘The other ones tend to be more strident’, Hitchens replied, The Institute of Public Affairs was an early critic of tobacco ‘and for that reason, easy to ignore’.33 plain packaging, which had been recommended in a major In January 2011, Hitchens was interviewed by the journalist report by the Australian Preventative Health Taskforce.38 In Brian Lamb for Q & A, on C-SPAN. ‘I suppose because I used to 2010, Tim Wilson, director of the intellectual property and free smoke very heavily I was afraid of always getting it in the trade unit at the IPA, pointed out that the British government lung’, he said.34 ‘I always knew that there's a risk in the bo- had rejected plain packaging because of lack of evidence that hemian lifestyle and I decided to take it because whether it's it would reduce youth smoking,39 and pointed to IPA calcu- an illusion or not … it helped my concentration, it stopped me lations that Australia's obligations to compensate tobacco being bored, stopped other people being boring … it would companies for interference with their trademarks could cost make me want the evening to go on longer … to enhance the $3 billion annually.40 moment. If I was asked, would I do it again, the answer is In a six to one decision in 2012, Australia's High Court probably yes, [but] I'd have quit earlier, possibly, hoping to get rejected a lawsuit brought by tobacco companies claiming away with the whole thing’.34 that the legislation constituted an ‘acquisition’ of property ‘It sounds irresponsible if I say yes, I'd do all that again … that triggered an obligation under the constitution to provide [b]ut the truth is it would be hypocritical of me to say no, I'd just compensation.41 Claims against Australia by tobacco never touch the stuff if I'd known, because I did know, exporting states under World Trade Organization agreements everyone knows … .I decided all of life is a wager … .It's are pending.42,43 strange, I almost don't even regret it, though I should.34 Contrary to the fears of the IPA, evidence is confirming that Recalling the death of his father, Hitchens writes: ‘[M]y plain packaging laws are effective in encouraging quit at- father was a pipe smoker and a reasonably consistent drinker tempts.44 For example, Young and colleagues found that four too. And I can't but think that that's what contributed to it. We weeks after the legislation took effect, calls to the NSW quit- didn't learn much from his death, my brother and I, because line had increased by 78%. Their analysis also showed a sus- he was diagnosed and died almost right away … .[I]t wasn'ta tained, projected impact over 43 weeks.45 Another study teaching moment’.34 found that one year after implementation, contrary to the During his illness, Hitchens avoided self-pity and main- doomsayers, plain packaging had not resulted in a flood of tained his well-known atheism. However, his public expres- cheap asian cigarette imports, or a rise in use of illicit or sions of regret were no less powerful for their subtlety. ‘In contraband tobacco.46 whatever kind of a ‘race’ life may be, I have very abruptly Despite this, in June 2014, Kerr claimed in The Australian become a finalist’,35 he wrote. ‘In one way, I suppose, I have that the previous government's ‘nanny state’ laws had

‘backfired’, boosting demand for cheaper cigarettes by more than 50%.47 Kerr referred to figures supplied by tobacco re- Conclusions tailers and manufacturers and quoted a 21-year-old Brisbane finance worker who claimed she had switched to a cheaper Howard Leichter has pointed out that ‘[t]he timelessness and brand, smokes more than before, and that ‘none of her friends persistence of holding the individual person responsible for had quit in the wake of the policy change’.47 Daube and his or her own health status has its genesis in one of the most Chapman point out that The Australian's campaign against distinguishing historical features of American culture and plain tobacco packaging includes at least 14 articles, including politics, namely the extraordinary emphasis on individual ’61 three front pages and three editorials.48 In the Daily Telegraph, rights and responsibilities. Deeply-felt assumptions about another Murdoch publication, Miranda Devine writes: ‘sur- the paramountcy of the individual are not unique to the prise, surprise. The nanny state strikes again. Labour's ‘plain United States, and if anything, they are becoming more deeply packaging’ rules for cigarettes have not stopped people entrenched. For example, when John Dombrink chronicles the ’ ' smoking’.49 slow demise of ‘moral politics in America s culture wars, According to the Australian Bureau of Statistics, the con- including subtle changes in public views about abortion, sumption of tobacco and cigarettes in the March quarter 2014 euthanasia, stem cells, and gay rights, the underlying factor was the lowest on record, with a reduction of over A$100 driving these changes is the growing importance of individu- million in spending, relative to December 2012, when the plain alism and shared assumptions about the overwhelming 62,63 packaging law went into operation.50 Excise and customs duty importance of personal autonomy. on tobacco fell by 3.4% in 2013, compared to 2012.51 Further- There are two sides to this libertarian impulse. The first is more, the National Drug Strategy Household Survey con- personal autonomy, which reveals itself in an instinctive op- ducted periodically by the Australian Institute of Health and position to any government intervention that affects the Welfare revealed that the daily smoking rate among those freedom of the individual. The second is personal re- aged 14 years and older fell from 15.1% in 2010, to 12.8% in sponsibility, reflected in the belief that individuals must be 2013.52 The proportion of those aged 18 to 24 who had never self-reliant, rather than dependent upon government, and in smoked increased from 72% in 2010 to 77% in 2013.51 The the belief that individuals are, in fact, wholly autonomous, average number of cigarettes smoked by regular smokers has free from influence, and adapted to the challenges of their also fallen significantly: from 111 in 2010 to 96 in 2013.51 In July environment. If the first side of the libertarian coin (personal 2014, the UK Advertising Standards Authority ruled that a autonomy) is a shield against the totalitarian state, the second multi million pound advertising campaign against plain side (personal responsibility), protects against the nanny packaging funded by the tobacco industry was misleading and state. should not be published again.53 In March 2015, both the Irish The case studies presented in this paper reveal a number of Box 1 and UK Parliaments passed standardised tobacco legislation important lessons ( ). The contempt that nanny state of their own.54,55 critics feel for public health regulation extends to public health advocates themselves and to organised efforts to improve the health of vulnerable and disadvantaged groups. For example, in the course of his review for the IPA, Kerr What can we learn? points to the ‘sprawling, expensive, anti-choice and anti- business public health bureaucracy and publicly funded Australia's experience with plain tobacco packaging illus- client groups of researchers, lobbyists, and various other … trates what for many will be blindingly obvious. Nanny state moralising busybodies that do their best to expand this ’ 36 name-calling fits hand-in-glove with the economic interests nanny state . Lest anyone miss the point, Kerr concludes: of tobacco manufacturers and retailers, and perhaps the ‘nanny Staters forget [that] people have brains of their own. broader ethic of neoliberalism and deregulation supported by They know bullshit when they see it. And that is what so some media organisations. Whatever their sincerity or purity much of the Nanny Statists agenda is-moralising, self- ’36 of belief, nanny state critics rally to the defence of corporate aggrandising bullshit. interests that profit handsomely from the sale of unhealthy Conspicuously absent from most nanny state rhetoric is products. any genuine attempt to engage in the messy business of Not surprisingly, business returns the favour. For example, defining the appropriate balance between the interests that in 2002, a spokesperson for the IPA acknowledged that his society has in an efficient private sector, a high standard of organisation received funding from tobacco companies.56 health across the community, and a free society that gives This was confirmed in 2012 by a spokesperson for British individuals genuine space to choose and to grow as in- American Tobacco Australasia57 and in 2013 by BAT in Lon- dividuals. One reason for this may lie in the distinction be- don.58 In the UK, the Institute of Economic Affairs has run a tween the totalitarian state and the nanny state referred to long-standing campaign against plain tobacco packaging, above. The real concern of nanny state theorists is not republishing all the self-serving, tobacco industry-funded freedom as such, but the role of the state. None of the case research which has been contested in Australia, including studies presented here genuinely restrict freedom, and yet industry-funded claims that plain tobacco packaging has they were vigorously resisted in the name of the nanny state. stimulated demand for cigarettes.59 As Daube and Chapman Nanny state name-calling reflects the irreconcilable contest have pointed out,48 the IEA also has a history of close ties with between what Robert Beaglehole and Ruth Bonita have called ’ 64 the tobacco industry and receives tobacco funding.60 a ‘social policy approach to healthy lifestyles , and a

Box 1: the state to be agnostic about the health of citizens, allowing What can we learn from nanny state rhetoric? market forces to dominate.

Nanny state criticisms reflect a (neoconservative) po- litical philosophy that asserts that governments Author statements should be agnostic about the health and the health- related choices made by member of the population; Ethical approval The nanny state critique is sticky because no one likes to think of themselves as manipulable, easily None sought. controlled, or too dumb to make their own decisions. This explains why nanny state name-calling is Funding directed at interventions that could help people to make healthier and more informed decisions (eg None declared. interpretive food labelling). Nanny state name-calling may also be the attractive to Competing interests those who do not wish to be reminded that their personal choices are harming their health. None declared. Nanny state critics don't always hold true to the libertarian principles they espouse; for example, they criticise laws that are surely justified even on narrow references libertarian grounds (eg laws protecting children from exposure to toxic tobacco smoke). Nanny state rhetoric is closely allied to defending the 1. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, economic interests of corporations that make money Aboyans V, et al. Global and regional mortality from 235 from health risks and unhealthy choices. In some causes of death for 20 age groups in 1990 and 2010: a cases it should be understood, and deserves to be dis- systematic analysis for the global Burden of disease study 2010. Lancet 2013;380(9859):2095e128. missed, as paid tobacco speech. 2. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair- Hitchens' critique of Governor Michael Bloomberg Rohani H, et al. A comparative risk assessment of burden of would make perfect sense if no one ever died or got disease and injury attributable to 67 risk factors and risk sick in New York City from the preventable diseases factor clusters in 21 regions, 1990e2010: a systematic analysis Bloomberg's policies were intended to address. The for the global Burden of disease Study 2010. Lancet occurrence of a preventable illness, like Hitchens' 2013;380(9859):2224e60. throat cancer, is precisely the time when the public 3. Daube M, Stafford J, Bond L. No need for nanny. Tob control 2008;17(6):426e7. interest that government policies seek to protect be- 4. Berridge V. The policy response to the smoking and lung comes visible. cancer connection in the 1950s and 1960s. Hist J Although illness and death occurs largely in the private 2006;49(4):1185. realm, even nanny state critics may have second 5. Fee E, Brown TM. The public health act of 1848. 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Available ‘from the public sphere (where they formed part of the busi- from: http://www.washingtonpost.com/blogs/the-buzz/post/ ness of government) to the private sphere (where they become rush-limbaugh-calls-georgetown-student-sandra-fluke-a- ’65 matters of only individual, familial or household concern). slut-for-advocating-contraception/2012/03/02/gIQAvjfSmR_ Neoliberals want to liberate the state from being held blog.html; 2003. accountable for the health of the population. It is not sur- 9. Kohan E. Obamafoodorama [Internet]: blogspot [cited 2014]. prising that, given the chance, they would also roll back the Available from: http://obamafoodorama.blogspot.com.au/ taxpayer funded provision of health care services. 2013/09/white-house-convening-on-food-marketing.html; 2013. During the 20th century, law has been an indispensable 10. Food marketing and advertising is none of Michelle Obama's part of many advances in public health, contributing to re- business2013. Available from: http://www.rushlimbaugh.com/ ductions in road traffic injuries, the control of infectious dis- daily/2013/09/18/food_marketing_and_advertising_is_none_ eases, safer and healthier foods, safer workplaces, and fewer of_michelle_obama_s_business; 5 June 2014. deaths from tobacco.66,67 Self-evidently, these advances 11. Hall MA. The scope and limits of public health law. Perspect 46 e would not have happened unless the state acknowledged its Biol Med 2003; (3):S199 209. responsibility for the health of the population. Nanny state 12. Sullum J. The war on fat: is the size of your butt the government's business? Reason 2004;8:20e31. name-calling may be a flippant and reflexive response to 13. Front-of-pack labelling updates: Department of health, policies one does not like. Ultimately, however, it is a call for australian government. Available from. http://www.health.

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Please cite this article in press as: Magnusson RS, Case studies in nanny state name-calling: what can we learn?, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.04.023