Monday, November 05, 2007

A program to almost eliminate cigarette consumption in Australia in one generation

I have been thinking about specific policies for substantially reducing the incidence of cigarette smoking in Australia. There are issues of ‘freedom of choice’ but I do not want to put weight on these here. I am certainly not interested at all in arguing the case for restricting smoking – that is self-evident to all sensible people and the case has been made on many occasions anyway. I am solely concerned here with developing a framework for policy that has as its objective the substantial reduction of the health damages associated with smoking in Australia.

How to do this?

Prohibition of smoking is not an option. As far as I know Bhutan is the only country to have banned smoking in public as well as the domestic sale of cigarettes. Bhutan is a poor country with a strong monarchy and only a small fraction of its population, around 1%, smoke. I do not favour such prohibitions in Australia since there are 3.4 million Australians who currently do smoke. These people have rights and would suffer high inconvenience and high adjustment costs from an outright prohibition. On practical grounds they would also vote out and replace any Government who sought to impose such restrictions.

But it seems reasonable to me to suppose that smokers in Australia should be encouraged to see that they are purchasing an addictive, dangerous drug namely nicotine. They should not be able to supply non-smokers with this drug or inflict passive smoking damage on others. There is, I argue, no case for allowing immature, irrational youth to take up smoking. Since almost all decisions to initiate smoking occur among young adolescents, this amounts to arguing that policy should target as a priority the complete elimination of smoking initiations.

Background. Cigarette consumption for most (probably 90%) of smokers involves addiction to nicotine. The most difficult issues associated with smoking are partly this addiction per se but also the fact that that the nicotine ingested is consumed with numerous other toxic products most notably, tobacco specific nitrosamines that cause cancers. Indeed the association between pipe smoking and cancer of the lip and tongue was recognised from the end of the 18th century. Cigarette smoke is acidic and, although much milder than other tobaccos, is efficiently absorbed by the lungs where it the major cause of lung cancer.

Cigarette smoking is not just a risky activity – it is a very risky activity. The average smoker loses 6-10 years of life as a consequence of smoking and one in two smokers die of diseases directly related to their smoking.

Tobacco companies have reluctantly come to publicly confirm what they have secretly known for over 50 years – that the product they sell, when used as intended, kills people. Their response these days is to trumpet the libertarian catchcry that smoking represents a free choice – our local branch of libertarian nitwits echo the exact same claim. That this is nonsense is clear from the fact that almost all smokers want to quit and regret their smoking habit. Quitting offers a strong payoff, in terms of increased average lifespan, even for lifetime smokers.

Australia has perhaps 3 million citizens who smoke daily and who are addicted to nicotine and about another 500,000 whom smoke less than daily and who are probably not addicted to nicotine. It has about 100,000 smokers under age 18 some of whom are dependent smokers and some of whom are casual smokers.

How might cigarette smoking be eliminated in the community in a way that respected the position of the large number of Australians who are addicted to nicotine? An alternative policy that might be considered as an alternative reference point might be a continuation of current policies perhaps with higher taxes and better-focused anti-smoking messages – a more-of-the-same policy. This is not necessarily a poor alternative option given successes in cutting smoking across the board and particularly in reducing youth smoking. But with this alternative there would still remain a huge pool of continuing smokers and a significant number of young people who would start smoking each year.

What policy would do the trick in almost eliminating cigarette smoking in one generation?

I think a set of nine policies would do this:

1. A key policy for dealing with existing addicted smokers lies in isolating them and making this group aware of their addicted status. This might be achieved by registering cigarette smokers who are addicted to nicotine as addicts just as it has been proposed to register heroin addicts. These addicts would then be supplied weekly supplies of the amount of tobacco needed from pharmacies which would be the only place where cigarettes were sold. Cigarettes would be sold in plain packaging (with only brand name, health warning, graphic health image and quit information on package) and out of sight of customers. Sales would only be made on the basis of a prescription from a doctor. Doctors would check cotinine levels in applicants for registration as a nicotine addict before agreeing to registration as a nicotine addict.

2. Cigarettes would be sold along with nicotine replacement therapy (NRT) pharmaceuticals and smokeless tobacco products with lower taxation of these latter products reflecting their lower relative risks. For example NRTs could be sold at marginal cost, smokeless tobaccos at marginal cost plus a tax of 20% and cigarettes at marginal cost on plus a specific tax of around 24 cents per stick. This is around current tax levels which are quite high. The objective is not to impose further financial hardship on smokers but to provide strong incentives to quit and to prevent cigarettes being sold to adolescents.

3. Sales or gifts of cigarettes to those under 21, not registered as nicotine addicts, would be liable to hefty fines that are comparable to those levied on the supply of other addictive drugs. Fines would also be imposed on non-addicted youth purchasers as well as suppliers.

4. All cigarette promotion would cease – including special events promotion such as in the Grand Prix. Indeed there would not be much need for non-defensive advertising since the demand for cigarettes by new smokers would disappear.

5. The provision of duty free cigarette purchases would end at all Australian entry points. Visitors to Australia would receive the right to bring several packets of cigarettes with them into Australia and a temporary right to purchase cigarettes for up to one month. Thereafter they would need to register as nicotine addicts with a doctor to continue their supplies. There would be hefty penalties on the resale of such cigarettes to residents.

6. Smoking would be banned in all workplaces, all public places, including public walkways and in cars with non-smoking passengers. Hefty fines would be levied for violations.

7. A publicity campaign would be launched to discourage smoking within the family home. Children and spouses of smokers could take tort actions against those practising smoking within the home on the basis of cotinine tests. Children and spouses of smokers would be eligible for publicly-funded cotinine testing to check on their passive smoking exposure. Persistently raised cotinine levels would provide grounds for those suffering from smoking-related diseases to take legal action against smokers.

8. Subsidised (and Medibank claimable) access to quit facilities would be offered to all registered smokers.

9. Potential applications for immigrants to Australia would lose entry score points if their urine tested positive for cotinine. It should be part of the normal system of appraisal since smokers imply above-average health costs for other Australians.

Am I serious about this as a policy package? By half I am. The proposal does not limit access to cigarettes by those addicted to them but makes it clear to smokers they are consuming an addictive drug. It limits deadbeat kids from initiating a habitat that they themselves will come to despise in a few years. In price terms it sends out the right signals on relative harms. As existing smokers cough themselves into early graves or, more hopefully, quit the disasterous habit of smoking, cigarettes would largely disappear without great social pain.

I’d be very interested in comments on this proposal but for goodness sake not on the ethics of curtailing smoking. That is not an issue being addressed here.


Anonymous said...

Why is the next man's smoking any of your business? You belong in jail

First anon. said...

It makes me want to light up even more, Harry.

It's the same thing as wanting to buy a Hummer if I could afford it, jsut to piss people off who are against it.

Spiros said...

Good on you Harry, all excellent suggestions.

While I agree that it is not practical to ban smoking, I think you overestimate the political clout of smokers. If they were so powerful, we would already have had a rebellion against such restrictions as currently exist and against tobacco taxes.

And don't forget, a lot of smokers are minors. They don't vote.

hc said...

Spiros, We know that paradoxically a lot of smokers support restrictions on smoking. There is evidence many support higher taxes and support such things as bans in pubs.

Most smokers want to quit so there could be an element of trying to 'tie yourself to the mast' to resist temptation from the Sirens of smoke.

I think most smokers by far are voters.

taust said...

I am so pleased that there are people around who worry about my behaviour.
How did human beings survive for some 100 thousand years without these people?

Chris Lloyd said...

It makes a lot of sense to concentrate on recruitment of new smokers and to draw a closer analogy with other drugs of addiction.

But I fear Harry that your suggestion #1 would also see a government voted out. The fatuous libertarian argument is just too easy to make and lends itself so well to the 15 second sound bite.

flashman said...

Harry, I agree that there are significant public health benefits in reducing cigarette smoking. But I worry that making cigarettes more difficult to obtain will cause a black market to flourish (as is the case with illegal drugs), so I can't say I entirely agree with some of your proposals - number 1 in particular.

derrida derider said...

Ah, there's no zeal like the zeal of a convert.

Maybe we could have "cigarette butt exchanges" modelled along the lines of needle exchanges - you only get new cigs when you hand in the old butts. That'd reduce littering too. Or you could take the old French approach and make production and distribution a government monopoly - that'll make sure the fags are unattractive to the younguns and expensive and only spasmodically available to the rest.

But it's all fantasy. Firstly, in a free society people should have the right to take themselves go to hell in a handbasket if they want - the role for government then is just in making sure adults know their destination. Secondly, you'd never get most of those proposals up in Australia.

I do think it's a good general approach to treat nicotine addiction as being in the same class as other major drug addictions. There's a lot to be said for medicalising and regulating the problem, if only because it might make people think of medicalising and regulating some of those other addictions rather than just throwing users into jail.

hc said...

dd, I am inclined to agree it is ambitious but there may be more tractable ways of doing this approximately. Its a starting point for me.

And of course to be consistent your argument implies we should legalise heroin.

You could allow cigarettes to be freely sold at $20 per pack or allow them to be sold in pharmacies at $12 per pack. Addicts could access smokes from pharmacies on the basis of cotinine tests.

The proposal is equivalent to FDA attempts in the US to regulate the sale of nicotine as an addictive drug. This is an accurate description.

stop smoking tips said...

Hello Harry

Great thoughts and hope everyone understand your healthy for your opinions...

''Smoking-related diseases claim an estimated 438,000 American lives each year, including those affected indirectly, such as babies born prematurely due to prenatal maternal smoking and victims of "secondhand" exposure to tobacco's carcinogens.''

observa said...

You seem to be singling out nicotine Harry, when the negatives of alchohol addiction, or simply casual consumption are equal or worse. Then there's the illicits. Your point about minors and beginning, ill-informed and negative addictive behaviour is valid despite the protestations of libertarians. However they also have a point about informed adult behaviour and the right to alter their consciousness in any way they see fit, up to the point where it infringes the rights of others. Passive smoking is a no-brainer on that account, as is drug driving or drug working and concomitant respobsibility. Many workplaces are recognising that now with drug and alchohol testing.

That said your prescription for smokers apoplies equally to all drug consumption. We already have a stringent pharmaceutical licensing and restriction system. Simply extend it universally to 'proscribed' chemcals and licence it. Then you can either pick up your endorsed licensed drug from a pharmacy or imbibe in the new 'hotels' for the purpose. User pays for the education and licensing of adult behaviour with strong penalties for distributing to the unlicensed(includes suspended) and ill- informed, particularly minors, which we would treat as akin to paedophilia. No more crime in the distribution process or community advertising whatsoever. Then if your drug behaviour impacts socially we suspend your drug licence and treat the problem, rather than suspending your driver's licence, or sacking you immediately. Then we can have a consistent and ethical approach to minors, re all drugs, while their young bodies and minds are growing and forming. The current approach is hypocritical and unsustainable and they know it.

observa said...

I might add that licensing allows the latest in research on medical and psychological ramifications of your particular drug to be disseminated to you easily, perhaps impacting your long term behaviour. As well a swipe card(licence to purchase) summary of your consumption patterns could be accessed strictly only by your doctor, for medical treatment purposes too, although it would help in compiling necessary medical research data and staistics.

observa said...

And when you think about it we should probably add analgesics to the 'proscribed' list, for the same reasons.

Sam Ward said...

The reason Harry singles out Nicotine and not alcohol is because he doesn't smoke but does drink.

And of course, alcohol is a problem, but not for smart people like Harry Clarke who can drink responsible. It's just the rest of us rabble who need to have our drinking and smoking monitored by government smoking and drinking police.

You have gone batshit insane Harry.

hc said...

observa, I single out nicotine since it is the major preventable cause of death in developed countries these days. Deaths from illicit drugs and alcohol are trivial in relation to smoking.

The swipe card idea might also be useful for thinking about treatment and quit options. But the main idea of registration is to impress on people they are consuming a harmful addictive set of drugs.

Sarah said...

The reason Harry singles out Nicotine and not alcohol is because he doesn't smoke but does drink.

Load of rubbish. When the person next to me has a beer, I don't suffer any of the negative health consequences that may be associated with that beer. When the person next to me has a cigarette, I'm forced to breathe their smoke and suffer the negative health consequences, despite my choosing not to smoke.

The argument above also leaves out the fact that at low levels of alcohol consumption, some health benefits are derived, whereas there is no safe level of consumption for cigarettes.

rog said...

Exactly Sarah, I have no complaint against smokers, drinkers etc but I dont want to be compelled to take part in their usage - passive smoking has known risks including death.

LDPers who want to smoke must ensure that their activities do not infringe on the rights of others to not smoke (suggestion, put your head in a bag)

Steve Edney said...

"When the person next to me has a beer, I don't suffer any of the negative health consequences that may be associated with that beer."

You may if they get drunk and agressive. There is a great deal of violence both in general and domestic associated with alcohol. You are in fantasy land if you think there is no negative externality associated with alcohol.

That said I am not for prohibition of either smoking or alcohol. Or indeed registering them.

Sam Ward said...

"LDPers who want to smoke must ensure that their activities do not infringe on the rights of others to not smoke (suggestion, put your head in a bag)"

I can ensure that not inviting you to my house. And I used to be able to ensure that by inviting you to leave my business premises.

But the government has banned the 2nd method already, and won't be too long before it bans the second.

Rog: What right do you have to come onto my property and tell me not to smoke?

If you don't like the 2nd-hand smoke in my House/Car/Pub/Office, nobody is forcing you to be there.

And nobody is forced to work there, either.

observa said...

I've got to say Harry death from smoking(not passive) is not an externality, whereas being put in a wheelchair by a drunk or drugged driver is.

And sarah, smokers don't want you to passively smoke. They just want the right and the places to quietly enjoy the poison of their choice.

observa said...

"When the person next to me has a beer, I don't suffer any of the negative health consequences that may be associated with that beer."

That's also a load of rubbish sarah as MasterO's experience last Sat night clearly demonstrated. Walking out of a nightclub with a mate, he bumped into an agressive drunk that had just been evicted and 2 girls were trying to get him into a cab. The drunk started on my less inebriated son who told him he's a really a lover and not a fighter and to go home and sleep it off mate. Sound advice as 6'4'' footballer, MasterO walked off until he heard footsteps running up behind him as the drunk was trying to king hit him from behind. Big mistake and MasterO was too quick and swung around and punched him once to the ground thinking that was the end of it. Not so as he got up a second, third and fourth time when finally MasterO, with sore hand had to kick him and belt his head against a plate glass window to finally get him to desist. He kept telling him to stay down to no avail until finally he was a bloody mess. Could easily have been the other way round if MasterO was some nerdy geek lover.

observa said...

Well they've just introduced the total ban on smokimg in SA pubs so what's next?,22606,22731454-911,00.html

adam said...

"There are issues of ‘freedom of choice’"

The derisive 'talking marks' you've put around this phrase speak volumes about the contempt with which you hold freedom of choice as a concept.

Fredrik said...

Harry, I am familiar with the works of Doll,Hill and Peto etc. And yes the worlds 1.2 billion smokers do have a reduced life expectancy. But they do still have very reasonable life expectancies. So I am glad to see that you are not an advocate of capital punishment. Because the state can never stop people from taking drugs of any kind. All the state can do is decide how big the prison population will be. I would guess that a substantial proportion of the prison population in Australia is a product of well intentioned prohibitionist legislation – and has it worked yet? And has it made Australia a happier country or could it be a less happy country? How does one measure happiness?
I would suggest legislation which respects the rights and wishes of both smokers and non-smokers. Legislation that and does not promote social isolation and social disharmony. So a good idea would be to allow private businesses to have well ventilated smoking rooms if that private business wishes to.

Anonymous said...

I think 2,4 and 8 are possible, but the rest all involve some measure of overkill.

I reckon wresting the sale of tobacco products away from supermarkets, newsagencies, service stations and the like, would be beneficial, reinforcing community expectations and desirable outcomes with respect to nicotine drug use.

But getting nicotine in 'stand-alone stores' and treated like alcohol itself would be a feat, let alone putting it on par with prescription heroin programs.

Anonymous said...

boo drugs

Paul said...

Some fierce comments. I for one would put up with almost any restrictions to end the damaging effects of cigarettes on the next generation.

Anonymous said...