One of the most pupular Nicotine Nazis is Frank Davis.

“Public health” as a term and a concept is rather unremarkable. After all, its value appears explicit and unequivocally desirable: maintaining the health of the public. But the legacy behind the term is problematic in Germany. As Machenbach indicates, Volksgesundheit––literally “public health”––was an official Nazi slogan, one that underpinned abhorrent racial hygiene efforts and progressive health interventions. It is uneasy to sit with this paradox. As historian Robert Proctor thoroughly details in The Nazi War on Cancer: Nazi Germany committed crimes against humanity and it implemented the world’s strongest anti-tobacco policies. Proctor also notes that it even provided the basis for the modern tobacco control movement itself, as Nazi scientists were the first to establish the connection between tobacco and lung cancer.

Sitting with the paradox, though deeply uncomfortable, raises a crucial question: What does it mean when actions taken to protect human health are the same as those employed, and even pioneered, by the Nazi Party? These actions should be examined – not to excuse or defend the Nazis by any means, but to gain more nuance to our understanding of history, and to better see the potential within so-called ‘progressive’ public health work to be corrupted. Part of maintaining a sense of ethics in public health involves unpacking our complicated histories of health knowledge being achieved through or alongside wretched means.

So, what exactly did Nazi tobacco control consist of? The following are some of the many examples provided by Proctor. To begin, the Nazi Ministry of Science and Education ordered all elementary schools to present the dangers of tobacco to students. They also established dozens of counseling centers by the 1930s to treat tobacco addiction. Beginning in 1938, German trains began to create no-smoking cars; in 1939, all uniformed police were banned from smoking; and soon, restaurants and cafes were prohibited from selling cigarettes to women as a measure for protecting maternal health. In 1941, the Nazis opened an Institute for Tobacco Hazards Research, advertised as the first of its kind in the world.

Sound forward-looking? Taken out of context, these actions would be described as ‘progressive’ – in fact, they mirror much of the anti-tobacco efforts seen today and accepted as necessary for protecting the health and wellbeing of the population: for fulfilling the mandate present in the term ‘public health’ itself. Yet, they do have a context: they were used with the intention to create a ‘pure,’ super-race marked by physical health, to be achieved through the cultivation of healthy habits and the elimination of the ill. In other words, utilitarian public health, whose benefits were reserved only for those with membership in the ‘super-race.’ So, really, not “public” health at all.

This history has profoundly impacted German public health and tobacco control today. Grüning, Strünck, and Gilmore describe a significant gap between Germany’s epidemiology and public health compared to the rest of the developed world (3). Public health is also explicitly not a federal priority, but none of Germany’s 16 states has its own ministry of health. Instead, as Busse and Blümel indicate on behalf of the World Health Organization, “public health” is simply lumped together with social affairs, youth affairs, or consumer protection duties. Many states, they write, have transferred public health responsibility to local governments or private-practice physicians. Which is not to say, however, that “health” is a free-for-all in Germany. Quite the opposite, in fact: Busse and Blümel also note that Germany invests heavily in health care, with health expenditure equivalent to 11.4% of its gross domestic product in 2012, one of the highest levels of health spending in the European Union.

Tobacco control remains particularly taboo, though, and it visibly bears the burden of its Nazi legacy. Schneider and Glantz profile how tobacco companies have used Germany’s history to frame tobacco control policies as “the New Fascism” and its advocates as “Nicotine Nazis”. For example, in 1995, the US-based tobacco company Philip Morris released its international “Where Will They Draw The Line?” campaign, equating hypothetical “smoking sections” in cities with the Nazis’ Jewish ghettos. Meanwhile, the Germany smoker’s rights organization “Fight Ordinances and Restrictions to Control and Eliminate Smoking (FORCES)” has tried to bring charges of Volksverhetzsung (agitation of the people) against the German WHO Collaborating Center for Tobacco Control (it should be noted that this charge is typically only used against neo-Nazis).

This language creates guilt by association. Tobacco control is denounced and discredited for being a priority within the Nazi regime, without consideration of its role beyond that chapter of history. Tobacco control does have value, and it is critically needed in modern Germany. For example, Grüning, Gilmore, and McKee note that tobacco is Germany’s most important source of chronic disease and early death, contributing to 17% of the nation’s deaths annually. Busse and Blümel of the World Health Organization meanwhile indicate that tobacco consumption is a key social determinant of health in Germany, concentrating tobacco-related illnesses among the poor.

And here we encounter another paradox: that the legacy of Nazi tobacco control could underpin positive changes in Germany’s public health environment. Germany’s unique history puts it in a position where there is a higher standard for maintaining democratic values. Nazi paternalism has engendered a deep suspicion of public health – meaning public health officials must respond with a stronger commitment to fair, participatory, and open practices. In doing so, Germany can negotiate a dark chapter of its history to serve as the foundation of a new public health culture that is appropriately self-critical due to an intimate awareness of the potential to be abused.

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