tag:theconversation.com,2011:/uk/topics/next-steps-for-tobacco-control-23434/articlesNext steps for tobacco control – The Conversation2015-06-18T20:10:51Ztag:theconversation.com,2011:article/425492015-06-18T20:10:51Z2015-06-18T20:10:51ZNext step for tobacco control? Make cigarettes less palatable<figure><img src="https://images.theconversation.com/files/85518/original/image-20150618-23239-i8uepw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Smokers respond to more filtered or more diluted cigarettes by taking bigger puffs and more of them. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-287436329/stock-photo-man-smoking-cigarette.html?src=M2GZNSHi9c62ORDzzBzwVw-1-19">Pe3k/F/Shutterstock</a></span></figcaption></figure><p>Australia has been a world leader in tobacco control. We were the first to introduce <a href="https://www.cancervic.org.au/plainfacts/">plain cigarette packaging</a> in 2012. </p>
<p>We were also one of the early jurisdictions to <a href="https://www.accc.gov.au/media-release/accc-resolves-light-and-mild-cigarette-issue-with-bat-and-philip-morris">ban</a> “light” or “mild” labelling on packs in 2005 and to remove tar, nicotine and carbon monoxide labelling on packs in 2006. Those steps were taken after it had become clear so-called “low tar” cigarettes were not less harmful.</p>
<p>The problem is these tobacco control measures stop outside of the pack, while the cigarettes inside <a href="http://www.tobaccoinaustralia.org.au/downloads/chapters/ch12_tobacco.pdf">remain</a> essentially the same. A logical next step is to regulate how companies engineer cigarettes to promote their use. </p>
<h2>Why regulate cigarettes?</h2>
<p>Taking regulation inside the packs to control cigarettes themselves can potentially achieve three broad aims. </p>
<p>The first is to reduce the <a href="http://tobaccocontrol.bmj.com/content/17/2/132.full.pdf+html">doses</a> of cancer-causing agents and other toxins received per cigarette. Regulators would first need to identify those harmful substances in tobacco smoke that can be reduced and then mandate reductions to specific harmful substances. If achieved, this would reduce the harms for current smokers, to some degree, especially long-termers who are unlikely to quit. </p>
<p>The second is to reduce their addictiveness, by controlling the doses of nicotine available to smokers. Getting the right dose of nicotine at the right dose rate is <a href="http://www.wisebrain.org/media/Papers/NeurobiologyofNicotineAddictionImplicationsfor.pdf">what gives smokers</a> that little buzz of enjoyment they seek but it is also precisely what makes smoking addictive. Addictiveness drives long-term smoking so reducing nicotine availability would also mean reducing harm at a population level, as more people successfully quit.</p>
<p>The third – and often overlooked – aim is to reduce the attractiveness or palatability of cigarettes to particular user groups separately from reducing nicotine availability. This means limiting the range of flavour varieties and flavour strengths available, as well as the tobacco industry’s ability to create impressions of reduced harmfulness. </p>
<p>Such restrictions would make it harder for teenagers experimenting with smoking to transition to being regular smokers and make it harder for long-term smokers to avoid thinking about the harmfulness of smoking. </p>
<h2>Less harmful? Not quite</h2>
<p>In 2006, Australia <a href="http://tobaccocontrol.bmj.com/content/12/suppl_3/iii61.full.pdf">ended</a> on-pack labelling of tar, nicotine and carbon monoxide yield figures, after having adopted it by voluntary agreement with the tobacco industry in 1981. </p>
<p>Tar, nicotine and carbon monoxide yield figures were a key part of the failed “low tar” harm-reduction system. The cigarettes labelled “light” or “mild” had reassuringly low tar, nicotine and carbon monoxide figures printed on the side of the pack and many smokers believed these cigarettes were less harmful. </p>
<p>Those cigarettes also had sensory <a href="http://cdrwww.who.int/fctc/guidelines/ArtElevenKozlowskiFive.pdf">characteristics</a> that are appealing to many smokers: less flavour strength, less “impact” or “catch” in the throat, and less lingering irritation on the throat and chest after smoking.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/85520/original/image-20150618-23223-een8oa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/85520/original/image-20150618-23223-een8oa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/85520/original/image-20150618-23223-een8oa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/85520/original/image-20150618-23223-een8oa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/85520/original/image-20150618-23223-een8oa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/85520/original/image-20150618-23223-een8oa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/85520/original/image-20150618-23223-een8oa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The terms light and mild have been replaced with smooth and fine.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/pyxopotamus/3565505580/in/photolist-6r59A9-r2BA4F-6qZXmP-6qZY9i-q5MjbX-6r5akJ-CJ1T3-6TdKFU-edfMM-d8aEj-e3nAp2-9Afpv-9AiV1-7ve4se-9AiUZ-6Kyhku-aiVm1g-q5yGFy-29zNZ-4fGnid-4JkCry-9kimqC-qWjjFQ-6r2SdV-6S1DDQ-6r5a7f-4WsVp2-bU9Pj4-b2Q3qe-Bsyws-6r5awC-8XEAjv-4QXydP-jCApZ-8v8nn8-cMot7-6UGbM1-84UUgx-mhhEjc-mhirmz-fteXc8-GzFUT-7PWVzm-5azjs9-6hDjoZ-3akKT7-3akKYs-efz9F-qfgU1S-a8mwyi">me and the sysop/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>Getting those figures off packs was an important step, once it became established they told smokers nothing about their actual intakes of harmful smoke constituents. But the “low tar” deception is part of a bigger problem of differences between cigarettes that smokers latch onto as evidence that some of them are less harmful. </p>
<p>After banning the <a href="https://www.accc.gov.au/media-release/accc-resolves-light-and-mild-cigarette-issue-with-bat-and-philip-morris">terms</a> “light” or “mild” in 2006, our tobacco industry simply replaced them, using “smooth” and “fine” as the new <a href="http://tobaccocontrol.bmj.com/content/14/3/214.extract">code words</a>. Each major brand family still has six or seven varieties, ranging from “original”, through “smooth” and “fine”, to “ultimate” – and that’s without counting the menthol varieties. </p>
<p>Smokers still select the taste strength and harshness level that best suits them, then can fine tune further by unconsciously <a href="http://cdrwww.who.int/fctc/guidelines/ArtElevenKozlowskiFive.pdf">adjusting</a> how they puff. </p>
<h2>Regulating filters</h2>
<p>It’s time for the government to ban filter ventilation to reduce the palatability of cigarettes. The government should regulate filters, specifying the sizes and designs that are permissible.</p>
<p>Since the 1960s, tobacco companies have used two engineering features to reduce the unpleasant sensations of smoking on the throat. Larger filters and tiny holes in the filter tipping paper called “filter vents” introduce fresh air into each puff and make smoking easier on the throat. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/84046/original/image-20150605-14125-12612jn.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/84046/original/image-20150605-14125-12612jn.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=408&fit=crop&dpr=1 600w, https://images.theconversation.com/files/84046/original/image-20150605-14125-12612jn.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=408&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/84046/original/image-20150605-14125-12612jn.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=408&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/84046/original/image-20150605-14125-12612jn.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=513&fit=crop&dpr=1 754w, https://images.theconversation.com/files/84046/original/image-20150605-14125-12612jn.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=513&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/84046/original/image-20150605-14125-12612jn.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=513&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Filter vents.</span>
<span class="attribution"><span class="source">Bill King</span></span>
</figcaption>
</figure>
<p>But smokers compensate for this. Smokers seek constant nicotine doses of around one milligram per cigarette. They respond to more filtered or more diluted cigarettes by taking bigger puffs and more of them. </p>
<p>There is <a href="http://chinancd.cn/contents/pdf/incomplete%20compensation%20does%20not%20imply%20reduced%20harm.pdf">evidence</a> that increasing filtration efficiency decreases smokers’ exposures to just a few carcinogens (a group called semi-volatiles) but increases their exposures to most of the <a href="http://www.ncbi.nlm.nih.gov/pubmed/17654296">harmful smoke components</a> in the vapour phase of tobacco smoke. (The vapour phase passes straight through standard cigarette filters.)</p>
<p>There is also <a href="http://www.surgeongeneral.gov/library/reports/50-years-of-progress/">evidence</a> that filter ventilation increases smokers’ exposures to a range of carcinogens by encouraging them to take more puffs from each cigarette, which are effectively smaller at the burning end of the cigarette (meaning more products of incomplete combustion). </p>
<p>Filter ventilation is also likely to contribute to smoke particles penetrating deeper into the lungs.</p>
<p>This evidence thoroughly undercuts any “we might make things worse by meddling” justifications for not acting to regulate the engineering of cigarettes. </p>
<h2>Regulating additives</h2>
<p>The government should also ban the use of all but a very limited number of <a href="http://www.who.int/tobacco/industry/product_regulation/factsheetingredients/en/">additives</a> in cigarettes. Sugars, honey, cocoa, liquorice and spices are <a href="http://www.tobaccoinaustralia.org.au/downloads/chapters/ch12_tobacco.pdf">added to cigarettes</a> to add the right “flavour notes”, cover unpleasant ones and also reduce other unpleasant sensations. </p>
<p>Additives provide the secondary means for the Australian tobacco industry to fine tune the sensory characteristics of cigarettes, making them easier to use and harder to quit. </p>
<p>Canada and Brazil have <a href="http://www.who.int/tobacco/industry/product_regulation/factsheetingredients/en/">already taken the lead</a> internationally by banning most additives, although Brazil unfortunately left sugars off the list. Canada exempted menthol cigarettes, but that might change soon, with Manitoba introducing a province-wide ban. </p>
<p>If Australia could set the strongest example so far by comprehensively regulating both of the industry’s tools for optimising the sensory characteristics of cigarettes – filters and additives – the benefits to public health would be substantial and we would once again be at the forefront of tobacco control.</p><img src="https://counter.theconversation.com/content/42549/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bill King is currently funded by a tobacco harm reduction research grant from the Victorian Health Promotion Foundation. His salary has previously been supported by grants and consultancies to research teams at the Cancer Council from the Australian National Health and Medical Research Council (NHMRC), US National Institutes of Health (NIH), Australian Competition and Consumer Commission and Australian Department of Health and Ageing. Bill King conducted research for the ACCC investigation into lights and milds. Their report to the ACCC is confidential.</span></em></p>Past tobacco control measures have changed the pack, while the cigarettes inside remain the same. A logical next step is to regulate how companies engineer cigarettes to promote their use.Bill King, Senior research officer, Cancer Council VictoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/423602015-06-12T04:55:32Z2015-06-12T04:55:32ZWe’ve reduced demand for cigarettes, next step is to target the supply<figure><img src="https://images.theconversation.com/files/84645/original/image-20150611-6793-14xb6ey.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Tobacco is sold in nearly every shop, on every street corner, in every neighbourhood.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-182633006/stock-photo-cigarettes-in-shopping-cart-on-wooden-table-on-dark-background.html?src=imYIyqmgFdEkcv1GRH75IQ-1-4">Africa Studio/Shutterstock</a></span></figcaption></figure><p>Australia has been hugely successful in reducing the number of people who smoke. Today, <a href="http://www.aihw.gov.au/alcohol-and-other-drugs/ndshs/2013/tobacco/">12.8% of people over age 14</a> smoke on a daily basis, which is nearly half the daily smoking rate in 1991 (24.3%). </p>
<p>This reduction in smoking has been largely achieved by curbing the consumer demand for tobacco products. Tax increases, tobacco advertising bans, smoke-free public places, graphic health warnings on cigarette packs and <a href="https://www.youtube.com/watch?v=kzoagsjlUv4">emotive anti-smoking mass media campaigns</a> have diminished the appeal of smoking and contributed to lowering smoking rates.</p>
<p>While these tobacco demand-reduction strategies have been widely implemented in Australia and internationally, comparatively little has been done to control the sale and supply of tobacco products. This needs to change. </p>
<h2>Unfettered supply</h2>
<p>Tobacco is sold in nearly every shop, on every street corner, in every neighbourhood. You can buy however much you want, whenever you like, from practically anyone. </p>
<p>The tobacco industry can make and sell as much product as it wants and generate profits with little regard to the accumulating public health toll. </p>
<p>New tobacco products can enter the market at any time with near zero restrictions on what ingredients can be added. There are no requirements for the industry to disclose how products are made or developed.</p>
<p>In practical terms, this means the tobacco industry can freely create products that are <a href="http://jama.jamanetwork.com/article.aspx?articleid=188023">increasingly addictive</a>, include ingredients that <a href="http://tobaccocontrol.bmj.com/content/9/3/283.short">mask the harshness of tobacco smoke</a>, and then sell them unreservedly on the market as if there were simply another consumer good.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/84644/original/image-20150611-6801-n9hlnm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/84644/original/image-20150611-6801-n9hlnm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/84644/original/image-20150611-6801-n9hlnm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/84644/original/image-20150611-6801-n9hlnm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/84644/original/image-20150611-6801-n9hlnm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/84644/original/image-20150611-6801-n9hlnm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/84644/original/image-20150611-6801-n9hlnm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Tobacco companies want to maximise profits and sell more cigarettes.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-238644967/stock-photo-man-smoking-cigarette.html?src=1yiNV7R-julD_ilk1G18fg-1-130">Miki Simankevicius/Shutterstock</a></span>
</figcaption>
</figure>
<p>Tobacco companies are required to maximise share prices and profits for stakeholders and must subsequently challenge any regulation or policy that threatens those profits.</p>
<p>Several different models have been proposed to better regulate the sale and supply of tobacco, with the eventual goal being to end the sale of tobacco products. </p>
<h2>Not-for-profit suppliers</h2>
<p><a href="http://tobaccocontrol.bmj.com/content/14/4/278.full">One possible regulatory</a> model is to transform the tobacco market from one controlled by for-profit corporations that have a mandate to sell more cigarettes, to one managed by a not-for-profit enterprise that has a mandate to promote public health. </p>
<p>This transformation could be achieved by purchasing existing tobacco companies at fair market value. </p>
<p>The goal of the newly formed pro-health tobacco supply monopoly then becomes to support, not stand in the way of, effective demand-reduction strategies. Tobacco products would also then be developed and sold in ways that facilitate quitting and discourage uptake.</p>
<p>Two barriers to this approach include the significant funds required to purchase these highly profitable companies and the complex legal issues due to the transnational operations of the companies.</p>
<h2>Price caps</h2>
<p>Others have suggested introducing <a href="http://tobaccocontrol.bmj.com/content/19/5/423.full?sid=f341755d-0ca0-4ee0-af2d-13cfa5376881">price cap regulation on tobacco products</a> that would set a maximum price that cigarette companies could charge for their products. </p>
<p>In high-income countries such as Australia that also have high tobacco taxes, tobacco companies have been enabled to increase prices alongside tax increases and thus maintain their profits in the face of shrinking sales. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/84643/original/image-20150611-6787-17ifcwi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/84643/original/image-20150611-6787-17ifcwi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=443&fit=crop&dpr=1 600w, https://images.theconversation.com/files/84643/original/image-20150611-6787-17ifcwi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=443&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/84643/original/image-20150611-6787-17ifcwi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=443&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/84643/original/image-20150611-6787-17ifcwi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=556&fit=crop&dpr=1 754w, https://images.theconversation.com/files/84643/original/image-20150611-6787-17ifcwi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=556&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/84643/original/image-20150611-6787-17ifcwi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=556&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Price caps would rein in excess tobacco profits.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-284887976/stock-photo-black-ashtray-with-cigarette-stubs-in-closeup.html?src=URATLPub-6tSDoQmZIh1cg-1-88">Garsya/Shutterstock</a></span>
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</figure>
<p>Capping cigarette manufacturers’ prices but not the price that consumers pay at retail, would still allow tax increases to remain a key tobacco control policy. </p>
<p>This approach would reign in the excess tobacco manufacturer profits that serve as a motivation to usurp effective tobacco control.</p>
<h2>Sinking lid</h2>
<p>New Zealand researchers have proposed a <a href="http://tobaccocontrol.bmj.com/content/19/5/431.short">“sinking lid”</a> approach to eliminating the commercial sale of tobacco products. </p>
<p>Legislation would introduce regular reductions in the allowable amount of tobacco released to consumers, with the goal of achieving zero commercial sales within a fixed period. A period of ten years has been proposed, with a reduction of 5% of the initial level allowed on the market every six months. </p>
<p>The sinking lid could result in increased efforts by manufacturers and retailers to maintain or increase demand, in order to maintain profits. But this could be combated by maintaining and increasing the traditional tobacco demand-reduction strategies.</p>
<h2>Limiting retail licences</h2>
<p>“Place” is a key part of the tobacco marketing mix. There is a <a href="http://www.ncbi.nlm.nih.gov/pubmed/20554363">greater concentration</a> of tobacco outlets in lower socioeconomic communities, even after adjusting for increased smoking rates. </p>
<p>The density of retailers and proximity of retailers to schools appear to increase smoking behaviour and tobacco purchasing by youth. </p>
<p>Venues such as bars, pubs and clubs and convenience stores are favoured much more by lighter smokers, suggesting these types of outlets may contribute to impulse purchasing.</p>
<p>But very little has been done to address and reform where and by whom tobacco products may be sold in Australia. </p>
<p>Nor is there a consistent approach to tobacco licensing across Australia. Most tobacco licensing schemes do little more than require sellers to pay a small fee in order to be able to sell. </p>
<p>The convenient supply of tobacco could then also be reduced by restricting the number and type of tobacco outlets through a system of limiting tobacco licences.</p>
<p>Unlike tobacco, Australia has a long history of controlling the supply of other potentially harmful, but legal products, such as alcohol, food, and prescription medications. While we’ve had great success reducing tobacco use through a demand-reduction approach, accelerating this decline and ending the tobacco epidemic will require creative and innovative policy approaches that involve changing the supply of tobacco.</p>
<p><em>Editor’s note: Comments will close at 5pm AEST today and will reopen on Monday morning.</em></p><img src="https://counter.theconversation.com/content/42360/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Becky Freeman has received funding from the NHMRC, ANPHA, the Cancer Council NSW, NSW Ministry of Health, the Australian Department of Health, WHO and the Sax Institute .</span></em></p>While tobacco demand-reduction strategies have been widely implemented in Australia and internationally, comparatively little has been done to control the sale and supply of tobacco products.Becky Freeman, Research Fellow/Lecturer, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/423622015-06-05T03:58:51Z2015-06-05T03:58:51ZMaking smoking history: the case for a smoker’s licence<figure><img src="https://images.theconversation.com/files/83316/original/image-20150529-24283-1pg555v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Smokers would not riot in the streets. Many would welcome it.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-150365273/stock-photo-man-takes-out-a-credit-card-from-the-wallet.html?src=pp-photo-153467753-aaZWbtQZSog_ielkvvKVDQ-3&ws=1">sanjagrujic/Shutterstock</a></span></figcaption></figure><p>I and many colleagues advocated for Australia’s pioneering <a href="http://ses.library.usyd.edu.au//bitstream/2123/12257/7/9781743324295_Chapman_RemovingtheEmperorsClothes_FT.pdf">plain tobacco packs</a> and today I’m always asked, “So what’s next in tobacco control?” The best next step is a <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001342">smoker’s licence</a>, that would operate in some of the same ways that we limit access to prescribed drugs.</p>
<p>I’m a regular drug user. Every morning I take a drug to manage blood pressure. I get my supplies from my neighbourhood dealer, but I can get the stuff almost anywhere.</p>
<p>My dealer-pharmacist won’t give me my stash unless I hand over a special drug-user’s licence from my doctor. It’s a prescription: a temporary licence to use a drug that will reduce my chances of having a stroke. It allows me to get a limited supply. If I want more, I have to start all over again.</p>
<p>If the chemist handed over my drugs without getting a prescription, he could be deregistered, heavily fined or even jailed.</p>
<p>Nearly everyone thinks this is a sensible way of regulating the supply of potent medicines. It reduces the potential for misuse and adverse drug interactions. It ensures use is supervised to monitor problems, so that the dose can be adjusted or stopped.</p>
<p>No one complains that this system is a huge erosion of freedom. No one says it’s demeaning or stigmatising to have to get approval to access these drugs. No one calls it a great illustration of the dreaded “nanny state”.</p>
<p>We do all this for products which promote health, prevent disease or severe pain. We do it for products which are good for us and might save our lives. What if we applied the sensible, near-universal licensing rules we have for prescribed drugs to the supply of tobacco? </p>
<p>What would happen if we treated tobacco not as an unremarkable item of commerce able to be sold in any quantity to anyone who wants it but as an unsurpassed agent of disease that is on track to kill a <a href="http://www.who.int/tobacco/mpower/tobacco_facts/en/">billion</a> this century.</p>
<p>Smokers would not riot in the streets. Many would welcome it. In Australia just <a href="http://www.aihw.gov.au/alcohol-and-other-drugs/ndshs/2013/tobacco/">12.8% of adults</a> smoke every day. Each year, about 40% make a serious but usually unsuccessful quit attempt. About <a href="http://www.ncbi.nlm.nih.gov/pubmed/15799597">90% regret</a> having ever started. So 90% of 12.8% leaves just 1.3% contented, leave-me-alone-I-love-it smokers. And many of these strongly support effective tobacco control policies.</p>
<h2>How it would work?</h2>
<p>A commencement date would be set a few years away. Any adult wanting to buy tobacco would apply online for a smoker’s licence with age-authenticating details such as a drivers’ licence or passport number to stop anyone obtaining multiple licences. You’d upload a photo. You’d get back a smart card licence needed to buy cigarettes at every purchase. </p>
<p>Tourists could get a temporary licence at airports, as they now get SIM cards.</p>
<p>There are two key elements. First, every licence applicant would have to pre-commit to how many cigarettes (or cigarette equivalents in roll-you-own tobacco) they’d want to smoke on an average day. There would be three bands: 1-10 cigarettes; 11-20; and 20-40. A tiny proportion of smokers smoke more than 40 a day.</p>
<p>Some would think “look, I don’t want to smoke. If I don’t get the licence, I won’t be easily able to buy cigarettes. Maybe I’ll now give smoking a miss.” Others would use the pre-commitment to lower their daily intake.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/83318/original/image-20150529-24233-1la8h8i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/83318/original/image-20150529-24233-1la8h8i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/83318/original/image-20150529-24233-1la8h8i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/83318/original/image-20150529-24233-1la8h8i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/83318/original/image-20150529-24233-1la8h8i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/83318/original/image-20150529-24233-1la8h8i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/83318/original/image-20150529-24233-1la8h8i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Very few smokers go through more than 40 a day.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-221788690/stock-photo-cigarettes-in-outdoors-ashtray-with-sand-closeup-image.html?src=86sV7bEpx9US6qKcrVTzuw-1-1">skyfish/Shutterstock</a></span>
</figcaption>
</figure>
<p>In shops, smokers would ask for their brand and swipe their licence, showing instantly if they had already reached their weekly pre-commitment limit or could buy more.</p>
<p>Every sale would automatically reconcile with the licensee who purchased it, so retailers would have to account for any stock that was not sold to a licensed smoker.</p>
<p>There would be a licence cost incentive to pre-commit to a lower daily maximum. So the annual cost of a 21-40 a day licence would be considerably more than a 1-10 a day licence.</p>
<p>The second feature is that all licence fees would be fully redeemable with interest if a smoker decided to surrender their licence permanently before the age of 40. Smokers who quit by middle age avoid much of the excess risk of death that they have over people who’ve never smoked. So having a financial incentive here could be very important. </p>
<p>If a 21-40 a day licence was to cost A$200 a year (about 50c a day, or the current cost of half a premium cigarette in Australia today), then a person who quit at 40 after getting their licence at 18, would get 22 years compound interest on their A$4,400 if they quit. At any time a smoker could look online and see how much cash they could get if they relinquished their licence.</p>
<p>What about people turning 18, the legal smoking age? Just as when you apply for a driving licence and study a thick book to pass a knowledge test, so too would new, commencing smokers have to pass a test to show they were knowingly taking the risks of smoking. </p>
<p>It’s widely said that “everyone knows the risks of smoking.” In fact, what most people know is only <a href="http://tobaccocontrol.bmj.com/content/14/suppl_2/ii8.full">very superficial</a>, top-line information.</p>
<p>So, what could go wrong?</p>
<h2>Wouldn’t this encourage a black market?</h2>
<p>No. Getting a licence would be neither difficult nor expensive (compared to the cost of smoking), so there are few reasons why most current smokers intending to continue would not obtain one. A licence would enable easy access to tobacco, whereas those unlicensed would need to find illegal supplies. </p>
<p>Here, some would argue that illicit drug trade flourishes in spite of such drugs needing to be sourced from criminals. The implication here is that many smokers would be similarly willing to transact with criminals. </p>
<p>However, this analogy is flawed because while illicit drugs can only be sourced illegally, tobacco would still be readily obtainable legally. It’s therefore difficult to see why significant proportions of smokers would elect to source their tobacco “underground” because of an easily obtained licensing requirement.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/83317/original/image-20150529-24241-1uzvs6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/83317/original/image-20150529-24241-1uzvs6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/83317/original/image-20150529-24241-1uzvs6y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/83317/original/image-20150529-24241-1uzvs6y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/83317/original/image-20150529-24241-1uzvs6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/83317/original/image-20150529-24241-1uzvs6y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/83317/original/image-20150529-24241-1uzvs6y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Getting a licence would be neither difficult nor expensive.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-232964731/stock-photo-a-young-man-smoking-a-cigarette.html?src=S0rdD3zTISs2QtMlqEuhMA-1-113">simone mescolini/Shutterstock</a></span>
</figcaption>
</figure>
<p>A purchasing limit of 40 a day would be insufficient to stimulate significant third-party purchasing schemes. There would not be enough profit incentive involved.</p>
<p>The main explanations for high demand for illicit tobacco are the cheaper price at which illicit tobacco sells, the ease of cross-border traffic in some nations, and the high levels of corruption in which illegal tobacco trade can flourish. None of these factors would in any way be influenced by a user-licensing system and so aren’t arguments against licensing.</p>
<h2>Wouldn’t it be horrendously expensive to set up?</h2>
<p>The scheme’s costs would include processing of licence applications, renewals, and licence surrender refunds (although much of this could be done online) and publicity about the scheme. The cost of the scheme would be drawn from the licensing fees, with retailers paying for the swipe card terminals. </p>
<p>The accumulated licence fees would be refundable to smokers wishing to surrender their licences. However, not all smokers would surrender their licence by the final age limit specified for surrender and refund (40 years). This would leave a large pool of funds that could be used to administer the scheme.</p>
<p>Young smokers with profound mental health or intellectual disabilities may be unable to pass the licensing test. Special provision could be made for another adult or carer to obtain a licence on their behalf, after consideration of their circumstances.</p>
<h2>Wouldn’t it stigmatise smokers even more?</h2>
<p>Every current smoker’s experience has been that tobacco products have always been sold alongside other unrestricted commodities such as confectionery, newspapers and magazines. This has powerfully conditioned the view that cigarettes are just “ordinary” commodities and that a proposal like this is self-evidently draconian. </p>
<p>Some smokers may feel that they are being treated like registered addicts, and that the licence epitomises their stigmatisation. But no one feels this way about their need to get a prescription for drugs.</p>
<p>When I started work in the mid 1970s, tobacco advertising was everywhere. All major sport was tobacco sponsored. You could smoke anywhere. Packs had warnings so small you needed a magnifying glass to read them. All this was said to be impossible to change. </p>
<p>It wasn’t. Most of it took time to play out from being seen as just nuts to being seen as totally normal. <a href="http://www.fctc.org/about-fca/tobacco-control-treaty/latest-ratifications">180 nations</a> have ratified the World Health Organization’s Framework Convention on Tobacco Control and an increasing number are seeing their tobacco caused disease rates falling.</p>
<p>We can make smoking history. Licensing might be a great way to turbo-charge the speed at which it happens.</p>
<p><em>This is an edited version of a video presentation available <a href="https://www.youtube.com/watch?v=wNfTBbTEgB8&list=UUhyxYzq0ZAB0iBw-A1l5jFA">here</a>.</em></p><img src="https://counter.theconversation.com/content/42362/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Chapman is part if a team which receives funding from the NHMRC to investigate unassisted smoking cessation. None of this funding benefits him personally.</span></em></p>I’m a regular drug user. Every morning I take a drug to manage blood pressure. I get my supplies from my neighbourhood dealer, but I can get the stuff almost anywhere.Simon Chapman, Professor of Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/422482015-05-26T06:15:38Z2015-05-26T06:15:38ZWhat’s next for tobacco control? A smoke-free generation<figure><img src="https://images.theconversation.com/files/82886/original/image-20150526-24745-1n2ct52.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Rolling the legal age of smoking forward will result in fewer new smokers.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/hazza96/5142844798/">Harry Phillips/</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>Each year 60,000 Australians and millions throughout the world die from cigarette smoking. One billion people are projected to die of tobacco-related disease by 2050. This is a national and <a href="http://www.who.int/mediacentre/factsheets/fs339/en/">international scandal</a>. </p>
<p>The <a href="http://tobaccocontrol.bmj.com/content/22/suppl_1/i22.abstract">tobacco-free generation</a> is a key “endgame” reform, recognised <a href="http://www.wctoh.org/updates/conference-resolutions">internationally</a> as part of a suite of measures to finally eliminate tobacco smoking. If legislation currently before the Tasmanian parliament passes, the state could be the first in the world to prohibit the sale of tobacco to people born after 2000. </p>
<p>Before we get into the detail of the proposal, let’s take a closer look at the problem. </p>
<p>Nicotine is a highly addictive drug which is usually obtained through inhaling the smoke of slow-burning tobacco leaves, plus many additives. According to the <a href="http://www.surgeongeneral.gov/library/reports/50-years-of-progress/fact-sheet.html">United States Surgeon General</a>, modern tobacco products are more toxic and addictive than ever, due to cigarette engineering by the tobacco industry, and more likely to cause cancer now than in the last century. </p>
<p>The addiction begins for most smokers as children and teenagers, but breaking the addiction is hard. <a href="https://www.saxinstitute.org.au/media/the-numbers-are-in-1-8m-australian-smokers-will-die-from-their-habit/">Two thirds</a> of these victims will die prematurely of disease related to their smoking habit, and the average life lost will be over ten years. </p>
<p>Smokers die of heart disease, stroke, chronic obstructive airways disease, asthma and many cancers, above all, lung cancer. Lung cancer is almost exclusively caused by tobacco smoking and has a <a href="http://canceraustralia.gov.au/affected-cancer/cancer-types/lung-cancer/lung-cancer-statistics">survival</a> rate of less than 15%.</p>
<p>Why are smokers “victims”? Because they were targeted when young, at a stage when their brains were immature and especially vulnerable to nicotine. This is the core business plan of the tobacco industry, with a constant need for new addicts; they need to get their targets <a href="http://www.sourcewatch.org/index.php/Project_16">hooked very young</a>. </p>
<p>The industry uses any tactic available to promote their product, and fights any attempt to constrain them. In the affluent West, including Australia, they use money to influence political parties directly, cozying up to individual politicians, in some instances to the point of <a href="http://search.informit.com.au/documentSummary;dn=351860324663735;res=IELHSS">corruption</a>. </p>
<p>In <a href="http://www.abc.net.au/news/2015-03-19/bill-gates-michael-bloomberg-launch-anti-tobacco-industry-fund/6331986">developing countries</a>, they shamelessly use tactics already outlawed in developed countries, and engage in intimidating <a href="http://www.bbc.com/news/business-32843205">legal actions</a>. They finance “<a href="http://www.who.int/tobacco/en/who_inquiry.pdf">front organisations</a>”, who then regurgitate industry mantras about “freedom of choice”, “nanny state”, or freedom of commerce for their “legal” but lethal product.</p>
<p>So, having set the scene, what is the tobacco-free generation legislation all about, and why Tasmania? </p>
<p>Tasmania has <a href="http://www.dhhs.tas.gov.au/publichealth/tobacco_control">smoking rates</a> 50% higher than elsewhere in Australia. Tasmania has widespread multigenerational poverty and social disadvantage, exactly the type of community especially susceptible to drug addiction in general, and tobacco-smoking in particular. </p>
<p>This leads to another twist or two in the cycle of deprivation: through the cost of the cigarettes, the high incidence of <a href="http://www.smokinginbritain.co.uk/read-paper/draft/6/How%20much%20improvement%20in%20mental%20health%20can%20be%20expected%20when%20people%20stop%20smoking%3F%20Findings%20from%20a%20national%20survey">mental illness</a> it initiates, long-term poor health in smokers and in babies born to smoking mothers.</p>
<p>Most anti-tobacco legislation has addressed the demand side of the problem: </p>
<ul>
<li>increasing the price</li>
<li>banning advertising</li>
<li>displaying images that shock</li>
<li>using unattractive colours on the packaging. </li>
</ul>
<p>All of these measures work to some extent, as do mass media campaigns and cessation support services, but mainly in middle class people. More is needed. </p>
<p>The tobacco-free generation is a supply side measure, but implements it in a way that is gradual, does not entrap or criminalise those already addicted, and is highly practical because the machinery to limit sales to young people under 18 is already in place and works well. </p>
<p>The onus is on the retailer not to sell or supply. Retailer compliance with the current law is 98% in Tasmania due to strong enforcement.</p>
<p>In practical terms what the tobacco-free generation <a href="http://www.parliament.tas.gov.au/bills/pdf/40_of_2014.pdf">legislation</a> would do if passed by Parliament is to roll forward, from January 2018, the age that a young person can be sold cigarettes, so that anyone born in the 21st century will never get to an age at which it is legal. </p>
<p>At first that sounds startling, but we do know that hardly anyone takes up smoking in their 20s or beyond. Most addicted smokers would like to give up and <a href="http://www.ncbi.nlm.nih.gov/pubmed/15799597">regret</a> starting. The tobacco-free generation is a very <a href="http://www.cancertas.org.au/about-us/position-statements/">popular measure</a>, in the <a href="http://www.smokefreetasmania.com/wp-content/uploads/2014/11/AIHW-NDS-2013-States-x-opinion.pdf">general population</a>, among smokers and young people.</p>
<p>The age at which young people started their addiction has <a href="http://www.aihw.gov.au/alcohol-and-other-drugs/ndshs-2013/ch3/">risen gradually</a> since the 1990s. The age at which smokers start tends to lag behind the “legal” age by about two years. This is because kids get their smokes <a href="http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/Publishing.nsf/content/BCBF6B2C638E1202CA257ACD0020E35C/$File/National%20Report_FINAL_ASSAD_7.12.pdf">from friends</a> slightly older than themselves, less often from parents or shops. </p>
<p>Thus the older the age of legal sale, the older the new smokers; so if we can roll the age forward, there will be fewer smoking friends and fewer new smokers, and ultimately just no new smokers. That is what we hope for, and this is what we think is achievable. This of course is why the tobacco companies are screaming blue murder.</p>
<p>The tobacco-free generation is a cry from the heart from people who have had enough. Those backing the amendment include many Tasmanian health professionals and <a href="http://www.smokefreetasmania.com/">advocates</a> who are fed up with the tobacco companies and their greed, and the complacency of some politicians in the face of so much avoidable suffering.</p><img src="https://counter.theconversation.com/content/42248/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Haydn Walters receives funding from the NHMRC. He is affiliated with Smoke Free Tasmania. </span></em></p><p class="fine-print"><em><span>Julia Walters is affiliated with SmokeFree Tasmania</span></em></p><p class="fine-print"><em><span>Kathryn Barnsley received research assistance fees for drafting the cabinet submission, first draft of the Bill and second reading speech for the tobacco-free generation Bill. She is convenor of Smoke Free Tasmania, a member of the Tasmanian Tobacco Coalition and has done anti-tobacco work for Cancer Council Australia and Tasmania.</span></em></p>If legislation currently before the Tasmanian parliament passes, the state could be the first in the world to prohibit the sale of tobacco to people born after 2000.Haydn Walters, Professorial Fellow, University of TasmaniaJulia Walters, Senior Research Fellow, Primary Health Care/Cochrane Airways Australia Coordinator, University of TasmaniaKathryn Barnsley, PhD student and tobacco researcher, University of TasmaniaLicensed as Creative Commons – attribution, no derivatives.