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.