It's time to focus on an endgame for tobacco regulation

New comprehensive research shows smoking imposes a heavy economic burden throughout the world, gobbling up almost 6% of global health spend and nearly 2% of the world’s GDP. In 2012 this amounted to US$1,436 billion (A$1.9 billion).

This is particularly evident in high income jurisdictions, like Australia, North America and Europe. Each year, smoking kills an estimated 15,000 Australians, and costs Australia A$31.5 billion in social (including health) and economic costs.

New initiatives in tobacco control are urgently needed. Plain packaging has been a success, but required steely determination by ministers to ensure continuity.

Smoking rates are declining in Australia, although the rate appears to be slowing. And there are still worryingly high rates of smoking in some populations and jurisdictions, such as the Northern Territory. In 2009 Australian researchers predicted smoking cessation rates would need to double to ensure Australian smoking prevalence dropped to the policy target of 10% by 2020.

Over a decade ago leading tobacco control expert Derek Yach, a Yale Professor and former senior World Health Organisation (WHO) executive, warned against complacency in tobacco control, and urged greater action. In 2016 Ruth Malone (former editor of the journal Tobacco Control) was still emphasising the point, highlighting current measures will not achieve an end to the tobacco pandemic. She asked,

Will caution and inertia shape another century of public health catastrophe?

Anti-science ideology

We are currently experiencing a crisis of public confidence in expertise, knowledge and evidence. The new US Vice President Mike Pence once famously wrote that “smoking doesn’t kill”.

New ways of thinking emphasise individual responsibility and de-emphasise population measures that regulate corporations. This is also having an impact on our health, and has led University of Melbourne’s Rob Moodie to call for change, saying:

The only evidence-based mechanisms that can prevent harm caused by unhealthy commodity industries are public regulation and market intervention.

Related to these global sentiments, the cigarette industry has some strategies in play. Big tobacco presents public arguments to counter reform, using terms that soften the need for regulation such as “nanny state” and “free choice”, and more recently “unintended consequences” and “sensible regulation”.

The tobacco industry is also actively evolving, for example through taking over e-cigarette production and sales.

Reform through endgame strategies and charismatic ideas

The tobacco endgame concept moves thinking away from the mere control of tobacco towards plans for ending the tobacco pandemic, and foresees a tobacco-free future. The unifying term “endgame” includes those policy approaches which orient researchers and decision-makers toward this goal.

WHO Director-General Margaret Chan championed endgame strategies in 2013 and urged a focus on precision, impeccable science, feasibility and realism.

Innovative strategies and “charismatic” ideas have also been proposed to counter an innovative tobacco industry. These ideas are canvassed below.

Reduction in retail outlets

In New Zealand, modelling undertaken at the University of Otago predicted reduction in retail outlets would modestly contribute to an endgame goal.

Others have suggested an increase in distance from home to the nearest tobacco retailer, or lowering density of outlets could assist quit rates.

A tobacco-free generation

This idea was first proposed in Singapore, and followed up in Tasmania. It’s a supply-side measure that would, from January 2018, prohibit the sale of tobacco products to any person born after the year 2000.

It has drawn criticism from the tobacco industry, but has 75% community support, and even 72% among smokers.

More broadly, Australian smokers do want the government to regulate the industry more heavily, as they believe the tobacco industry is partly responsible for the predicament they find themselves in.

Regulation of markets and cigarette engineering

The regulated market model proposes the tobacco market be controlled by one agency, which tenders to manufacturers for tobacco products and then distributes to retailers. This would, in effect, make tobacco a controlled substance, like methadone.

Reducing palatability of tobacco products, and the banning of filter ventilation and other elements of cigarette engineering have been proposed in Australia for some years. The idea of reducing addictiveness by lowering nicotine content is attractive, particularly as it would assist existing as well as beginner smokers.

The federal government contracted two consultants to provide reports on cigarette palatability and engineering in 2013. Late on Friday 27 January 2017 the heavily redacted documents were released under FOI. However, it is possible to see the extent of comprehensive research that has been undertaken.

One document includes the disclaimer:

No regulatory decisions have been made by the Department of Health or the Australian Government about potential new tobacco product content regulation controls or revised disclosure requirements for tobacco products.

There is no independent regulatory oversight or quality control on the content of cigarettes themselves, and no recall provisions.

The ‘sinking lid’ – an idea from New Zealand

Another supply-side reduction proposal is to require regular reductions in the amount of cigarettes made available for sale and to increase prices. This is the “sinking lid” idea. Strong border controls and geographical isolation are prerequisites in order to reduce the potential for smuggling. Therefore island nations and states are ideal places to experiment with this proposal. Considerable support exists for this approach.

Together, these endgame proposals to lower tobacco use should be actively explored and implemented as appropriate by governments around Australia. The economic and social costs of tobacco smoking remain enormous, and it’s time to take action.