Author - shireen lim

Brookline Article Aims to Create a ‘Tobacco Free Generation’

The notion of creating a Tobacco Free Generation is gaining traction worldwide.

2 doctors from Brookline, Massachusetts, are proposing a ban on sales to all persons in Brookline born after 1995, forever.

Balanga City in the Philippines is already way ahead in this, declaring their city to be the first Tobacco Free Generation city in the world on 18 March 2016. Step by step, we are moving towards being a Tobacco Free Generation!

Article from Brookline.Wickedlocal.com:

6th April 2016
By Jenna Fisher for brookline.wickedlocal.com

BROOKLINE – As groups across the state move to increase restrictions on the sale and use of tobacco, two Brookline health professionals want to convince the town to be the first in the country to adopt a “tobacco free generation” policy.

Petitioners John Ross and his wife Megan Sandel are area doctors and see a number of patients with tobacco-related problems. Their warrant article for May’s Town Meeting calls for a ban on the sale of tobacco products to anyone born after 1995. Such a ban would encourage a generation of nonsmokers, they said.

“This is out of character for us,” said Ross. “I never really got involved in Brookline government. I just got fed up with seeing so many patients dying and felt this was a way to get involved and change something.”

Ross is a doctor at Brigham and Women’s Hospital in Boston. In addition to being a pediatrician who sees a number of children suffering from smoke-related problems, Sandel is an associate professor of pediatrics at the Boston University Schools of Medicine and Public Health, the medical director of National Center for Medical-Legal Partnership, and a principal investigator with Children’s Health Watch.

In 2014, Brookline raised the smoking age to 21, which some experts say helped lower smoking rates among teenagers at Brookline High School, the TAB reported.

According to a recent survey put out by Brookline’s Health Department, the rate of tobacco use among high school students in Brookline sits at about 5 percent, compared to about an 11 percent in the state and 16 percent in the US.

Still, Ross said the number is still too high.

“I would take the position that tobacco is a drug. It’s a defective consumer product. If it were a new consumer product, there is no way that it would be considered [safe for] sale,” he said.

On average a smoker lives 10 years less than a nonsmoker. And tobacco caused more than 480,000 deaths each year (including deaths from secondhand smoke), according to the Centers for Disease Control and Prevention.

In Massachusetts, tobacco use contributes to the death of 9,300 people and costs $4.08 billion in health care bills each year, according to activist campaign group Tobacco Free Kids, which led a march last month at the capital.

Cigarettes are the number one cause of preventable death in the United States, said Ross.

“People may talk about consumer choice, but this is really an addictive drug on the level of an opiate,” he said. “Tobacco is the only consumer product that kills you when used as directed. There’s no equal in terms of disease and harm it causes.”

At first, the couple hoped to ban the sale of tobacco to everyone in Brookline. But after some thought they decided to scale back.

“We don’t have any desire to put anybody out of business,” Ross said.

Ross and Sandel are proposing a ban of sales to all persons in Brookline born after 1995, forever. That would mean if you are currently of legal age to smoke, you would still be able to smoke, but if not, you wouldn’t be allowed to start.

This would mitigate some of the impact to retailers by decreasing sales by about 2 percent a year, he said, at the same time protecting youth by making it more difficult to start smoking.

“Every day that I come to work, I see people who have been damaged in one way or another by tobacco, COPD, new diagnoses of cancer, heart disease or many of the ways that tobacco can impact your health. At some point I realized the most effective way to treat the ravages of tobacco is to prevent them from happening at all,” he said. “If [the warrant article] did pass, it would be another example of Brookline breaking ground in the fight against tobacco.”

Ross said reaction in the medical and public health circles has been positive. The Public Health Advocacy Institute at Northeastern University – which has defended municipalities in the state that have enacted various restrictions on tobacco – has agreed to defend the town pro bono should it run into serious opposition.

“Of course the town has the right to handle its own defense of its legislation, but we would be able to go into court and do the written work and handle that on behalf of that or in conjunction with Brookline if there is a challenge from either retailers or another part of the tobacco industry,” said Mark Gottlieb, executive director of the public health advocacy institute at Northeastern University School of Law.

And there’s a chance of litigation.

“This would be a first of it’s kind. In general the more restrictive a piece of legislation or health policy regarding a tobacco, the more likely it is to be challenged, usually by retailers,” he said.

But he’s optimistic.

“Legally we’re quite confident that this is a strong approach that would be successful,” he said.

In Brookline, small convenience stores are the primary source of cigarettes. It’s unclear what the impact might be on them.

“That’s something that the community carefully needs to review. How does it affect existing businesses?” said National Association of Convenience Stores’ Jeff Lenard, based in Virginia. Lenard added that about a third of convenience store revenue comes from tobacco products.

Ross and Gottlieb seem to have given it some thought.

In late 2014, the town of Westminster toyed with the idea of banning all tobacco sales. That was met with an unpleasant backlash against the board of health, said Gottlieb. The meeting to discuss it was overwhelmed with protestors, he said.

“The Tobacco free generation concept is a much more moderate and very gentle phase out. It’s really just affecting a tiny amount of sales each year. It’s something that gives the retail company a lot of time to adapt to. And ultimately achieve the same goal which is to stop the cycle of youth addiction.”

Some 95 percent of users start using tobacco products before the age of 21, said Gottlieb. “I think this proposal is a very elegant way of achieving a very important health goal. If Brookline adopts this and becomes the first in the nation it will open a lot of eyes across Massachusetts.”

 


This original article can be viewed here.

 

Human rights and ethical considerations for a tobacco-free generation

Tob Control 2015;24:238-242 doi:10.1136/tobaccocontrol-2013-051125
RESEARCH PAPER

 

Correspondence to
Yvette van der Eijk, Centre for Biomedical Ethics, National University of Singapore, 10 Medical Drive 02-01, Singapore 117597, Singapore; y.vandereijk@nus.edu.sg

Received 29 April 2013
Revised 16 August 2013
Accepted 20 September 2013
Published Online First 10 October 2013

 

Abstract

In recent years, a new tobacco ‘endgame’ has been proposed: the denial of tobacco sale to any citizen born after a certain year, thus creating new tobacco-free generations. The proposal would not directly affect current smokers, but would impose a restriction on potential future generations of smokers. This paper examines some key legal and ethical issues raised by this proposal, critically assessing how an obligation to protect human rights might limit or support a state’s ability to phase out tobacco.

 

Introduction

Most anti-tobacco policies and legislation ratified under the WHO Framework Convention on Tobacco Control (WHO FCTC) aim to reduce smoking prevalence. Recent years, however, have seen the rise of tobacco ‘endgame’ proposals that aim to end smoking altogether.1 One such proposal, termed the ‘Tobacco Free Generation 2000’ (TFG2000) would deny tobacco supply to any citizen born on or after a certain date (in this case, 1 January 2000) in addition to current restrictions, thus phasing out tobacco consumption for good. Public support would be sought through education initiatives and promotion of TFG2000 to the post-2000 birth cohorts. Regions most involved in this specific movement so far include Singapore, Tasmania (Australia), and Guernsey (UK). The rationale is that current policies based on the WHO FCTC have been able to reduce smoking prevalence, depending on the country, to roughly 15–25%, but no further.2Smoking continues to kill roughly 6 million people per year worldwide, a significant proportion of whom have never smoked.2 Moreover, in places such as Singapore, smoking among younger generations is on the rise.3 Together, this suggests that measures beyond the FCTC, that target youth in particular, are necessary to further reduce the public health burdens of smoking.

In 2010, a Singaporean TFG2000 proposal was published in this journal.3 Population surveys conducted in Singapore indicate strong public support: 60.0% of smokers and 72.7% of non-smokers surveyed would endorse TFG2000. The authors argued that their proposal more correctly conveys the message to young people that smoking is not an appropriate social behaviour at any age. It also allows governments to continue to collect tobacco tax revenue for several decades and does not create further impositions on current smokers. Implementing the ban only for citizens and Permanent Residents (PRs) ensures tourism and foreign employment trades are unaffected. Hence, given the public support, the phase out was regarded as ‘a feasible next step in reducing tobacco consumption’.3

The TFG2000 proposal also caught on elsewhere. Earlier this year, a unanimous vote in Tasmania’s Upper House passed the same proposal.4 In Guernsey, the idea is also being considered.5 Finland6 and New Zealand7 also share visions of a tobacco endgame, but their exact strategies for achieving it have not been determined yet. It is worth noting that the five places mentioned all have tough anti-tobacco policies that also target smoking uptake in youth, and no tobacco growers. Hence, they are more likely candidates for TFG2000 than countries where tobacco growing contributes substantially towards the economy, or where smoking is a highly accepted part of the culture. The proposal, however, also raises important questions about whether its goal—to fully phase out tobacco consumption—is ethical and legally defensible in light of the current human rights debate, and whether certain practical challenges to its implementation could be overcome. Concerns about loss of tax revenue and compatibility with world trade and investment law are also relevant, but beyond the scope of this paper, which focuses on the human rights issues involved.

Our central argument is that TFG2000 is compatible with human rights principles, and may even form part of a successful human rights-based strategy for tobacco control.

 

The relationship between human rights and tobacco control

Human rights were established to protect fundamental values such as the ability to live, have a family and be free from cruel treatment. In this paper, we will analyse the TFG2000 proposal in reference to four international human rights documents: the Universal Declaration of Human Rights8 (UDHR), the International Covenant on Civil and Political Rights9 (ICCPR), the International Covenant on Economic, Social and Cultural Rights10 (ICESCR) and the Convention on the Rights of the Child11 (CRC). These instruments themselves have no direct legal effect; the idea is that states that have signed the document incorporate these rights into their own legal systems. Thus, aggrieved individuals may make human rights arguments in their state’s domestic courts or similar systems. State compliance with the principles outlined in human rights treaties is tracked using periodical shadow reports, submitted to the UN by non-state bodies such as non-governmental organisations (NGOs).

Previously, it was suggested in this journal that the human rights to life, health and a healthy environment should be used as the basis for a ‘right to tobacco control’.12 This would impose a corresponding duty on the state to pursue various means of restricting tobacco use. Human rights rhetoric, however, has been used on both sides of the debate. Pro-smoking advocates have drawn upon the rights to liberty, self-determination and privacy in support of a ‘right to smoke’. Would ‘tobacco-free generation’ legislation violate or support these rights?

Below, we examine some key human rights debates and their relevance to the TFG2000 proposal: the rights to life and health, the rights to liberty and self-determination, the right to privacy and rights to equality and non-discrimination. We finish with some practical indications for the future.

 

Human rights to life and health: protecting children from second-hand smoke

The human right to life is a fundamental right recognised in UDHR article 3, ICCPR article 6 and for children in CRC article 6. The human right to health is recognised in ICESCR article 12. Human rights may be ‘positive’ or ‘negative’: for example, an entitlement to state provision and funding for programmes that contribute to good health (positive) or a right to be free from the actions of others that may impair health (negative).13 Thus, the dangers posed to non-smokers by second-hand smoke (SHS) can be construed as an infringement of a non-smoker’s negative rights. The effects of SHS, especially in children, are worth noting: passive exposure to parental smoking leads to middle ear infections, respiratory diseases including asthma, the worsening of serious conditions such as cystic fibrosis and asthma, and in some cases, death.14 Given these clear risks, it could be argued that failing to prevent child exposure to SHS affects their basic rights to life and health, and their right to ‘a clean and safe environment’ (CRC article 14).11

Arguably, governments already protect non-smokers to some extent through public smoking restrictions. Such measures are helpful, but cannot eliminate SHS completely, leaving many non-smokers, especially children, at risk in private places such as the home. Children with asthma in particular are at risk of developing respiratory conditions; but even in countries such as the USA, where public smoking bans are common, the majority (53.2%) of children with asthma are still exposed to SHS.15 Governments could go one step further by banning smoking inside family homes, but enforcing such a rule would be difficult. In other words, so long as cigarettes are freely available, and contact with SHS is possible, it is practically impossible to eliminate SHS exposure to children, even with very stringent laws against SHS.

The TFG2000 proposal would not immediately protect all children from SHS, because those born just after 2000 may still be exposed to the SHS of smokers born before 2000. However, full child protection from SHS, and thus the right to be free from the health effects of SHS, may be realised in the long run, as tobacco is phased out and later generations that follow are no longer exposed to SHS by their elders born after 2000.

 

Human rights to life and health: protection from active smoking and addiction

Human right principles can also be invoked to justify protecting individuals from the harms of active smoking. Most smokers start before adulthood, at a time when the capacity for rationalised, long-term decision-making is not yet fully developed. Many adolescents are lured into cigarette smoking as a rite of passage into adulthood, usually through their peers, unable to fully conceive of the addictive grip of nicotine, and the health impacts they will later experience.16 Yet, under CRC article 6: ‘governments should ensure that children survive and develop healthily’.11 Thus, it is reasonable to suggest that governments have a duty to protect children from initiating active smoking, and from developing nicotine addiction.

Furthermore, under ICESCR article 12, adults are also entitled to: ‘the enjoyment of the highest attainable standard of physical and mental health’, including the ‘prevention, treatment and control of epidemic, endemic, occupational and other diseases’.10 Active smoking is an epidemic that claims over 6 million lives per year; nicotine addiction can significantly impact the liberty, health and mental wellbeing of an individual. The rights to life and health, recognised in the WHO FCTC, may therefore merit the further protection of children and adults from active smoking and nicotine addiction.

The TFG2000 proposal would protect an entire generation of citizens from active smoking in adolescence and throughout their entire adult lives. It would address the rite of passage effect that attracts many underage smokers to tobacco, which supports children’s right to survival and healthy development. Protection would then continue into adulthood, in support of the right to the highest possible standard of physical and mental health.

Despite these arguments, it must be noted that there is a great deal of uncertainty and contestation over the exact meaning of human rights articles, particularly in the sphere of public health.17–19 Given the ambiguities, it is difficult to argue that states are compelled to adopt a tobacco phase out to ensure that their citizens’ health is not affected at all by active or passive smoking. Nevertheless, for countries that choose to adopt a phase out, the policy could be justified by reference to human rights principles. However, a fundamental tension arises: how should the state balance its duty to protect life and health against its obligation to respect individual liberty?

 

Human rights to liberty and self-determination: balancing against harm to others

The human right to liberty is recognised in UDHR article 3 and ICCPR article 9; the right to self-determination in ICESCR article 1 and ICCPR article 1, where it is defined as the right to ‘freely pursue … economic, social and cultural development’.9 ,10 In pro-smokers’ rights rhetoric, these two rights are often translated into a ‘right to smoke’.

A right to self-determination may be translated into a right to smoke if smoking is to be viewed as a pursuit of economic, social or cultural development. But to frame a behaviour that is highly destructive to oneself and others as ‘social and cultural development’ is a fragile argument at best; thus, it is difficult to maintain an argument that frames smoking as falling within the scope of a right to self-determination.

If health is seen as a choice, some may argue that the right to smoke can be construed as a liberty right. However, there are several points of tension with this view. Tobacco-related illnesses and deaths have adverse socioeconomic consequences for families, communities, healthcare systems and public resources, while SHS can affect children and non-smokers. Thus, smoking affects others, both directly and indirectly. In such cases, human rights instruments permit balancing, as the exercise of rights and freedoms can be subject to limitations to secure: ‘the just requirements of morality, public order and the general welfare in a democratic society’.8

In addition, given the addictive properties of tobacco, it can be suggested that smoking is incompatible with the notion of ‘liberty’, as the addict is not entirely free to choose whether to continue smoking or not. Furthermore, in practice, governments do restrict liberty to protect citizens from the effects of harmful and addictive psycho-active drugs, such as opium, heroin and cocaine; none of which have caused anywhere near as many deaths as tobacco. A tobacco phase out would thus be consistent with the way in which other hazardous, addictive substances are regulated.

Thus, it can be argued that the TFG2000 proposal imposes liberty restrictions on would-be smokers born after 2000; but not beyond a level that unjustifiably violates their liberty rights, given the balance of interests at stake.

 

The human right to privacy: autonomy and identity

The right to privacy is recognised in UDHR article 12 and ICCPR article 17: ‘no one shall be subjected to arbitrary … interference with his privacy, family, home’.8 ,9 Three recent legal cases—one in England, the other two in New Zealand—illustrate how the right to privacy may be construed in relation to claims to a putative ‘right to smoke’.

In the English case, R. (on the application of N) v Secretary of State for Health, residents of a high-security hospital filed for an exemption to indoor smoking restrictions.20 The highly secure nature of their setting meant that, given smokefree policies, most residents would be forced to give up smoking. The appellants argued this was incompatible with the right to respect for home and private life under article 8(1) of the European Convention on Human Rights (ECHR), an article which is often used as the basis for autonomy-driven human rights arguments.21

Their request, however, was denied on the basis that privacy rights are limited in what they can protect. Smoking was regarded as beyond these limits: a 2–1 majority of the Court held that smoking is not sufficiently close to either the integrity of identity, the development of personality, or the ability to establish and develop relationships with others to merit protection under Article 8(1) ECHR. Going further, the majority also considered whether, if Article 8(1) were ‘engaged’, the smoking ban could be justified under Article 8(2), which allows limitations to Article 8(1) that are in accordance with the law and ‘necessary in a democratic society … for the protection of health … or for the protection of the rights and freedoms of others’.21 It was concluded that, as there is strong evidence of the dangers of smoking to smokers and to those subject to SHS, a ban could be justified under certain circumstances. Substantial health benefits arose to the patients from the ban, and the disbenefits were insubstantial.

In the first New Zealand case, Taylor v The Attorney-General and Ors, a resident of a prison filed for a similar exemption to a smoking ban inside Auckland Prison. Contrary to the English case, however, the exemption was permitted, inter alia, on the basis that forcing prisoners into nicotine withdrawal was ‘not humane’. Depriving the prisoners of tobacco, seen as an ‘otherwise lawful substance’, was considered ‘too restrictive’.22

By contrast, in the second New Zealand case, B v Waitemata District Health Board, which also had similar facts to the English case, a different conclusion was reached. Citing the English Court of Appeal decision with approval, it was held that a no-smoking policy had significant advantages and caused only relatively minor disadvantages to the applicants. Furthermore, if there was any limitation on human rights and freedoms, it was said to be of the type that could be demonstrably justified in a free and democratic society.23

The precedential value of these cases in relation to the TFG2000 proposal is uncertain, as the special circumstances of the complainants’ detention in secure settings exerted a strong influence on the outcomes. The smoking bans forced smokers to go into withdrawal, whereas the TFG2000 proposal does not affect current smokers. Nevertheless, it is notable from the English case and the Waitemata ruling that the interests of current smokers to be free to smoke without state interference was not recognised as engaging the right to privacy. Extending this reasoning, the claim that a minor who is currently too young to buy cigarettes has a human right to weigh and balance the risks and benefits of smoking when (s)he becomes old enough to legally purchase cigarettes would appear to be very weak indeed.

 

Issues with discrimination and inequality

Equality rights before the law are recognised in UDHR articles 2 and 7, ICCPR articles 2 and 26, and ICESCR article 2: ‘without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth, or other status’.8–10Denying tobacco to citizens and PRs whilst permitting foreign nationals to smoke may raise the objection that it constitutes discrimination on the basis of nationality. The inclusion of ‘other status’ implies that the list is not exhaustive and other grounds, such as birth cohort, may be incorporated into this category. Specific targeting of post-2000 cohorts could create friction between groups born in 1999 and 2000, as the former may be perceived to have an unfair ‘advantage’ over the latter (or vice versa).

There are two counterarguments to these objections. First, a state could argue that any differential treatment on the basis of nationality had a reasonable and objective justification and pursued a legitimate aim, that is, the balancing of its domestic health policy against other pressing social needs, such as the desire not to damage the tourist industry or interfere with the inflow of foreign workers. The second argument is that the TFG2000 proposal has a sound and reasonable basis: to protect future generations from the health effects of active and passive smoking. It may be argued, then, that tobacco supply should be denied to everyone to avoid discriminating between different groups. However, this would affect current smokers, potentially forcing many into withdrawal (depending on availability and use of nicotine replacement or other therapies), which could be considered ‘not humane’ (see the argument above on privacy rights). Thus, there are also good grounds for applying the measure only to people who are less affected by the impacts of nicotine addiction.

The issue may also be framed as one of equality of liberty: the argument that one group possesses the legal freedom to smoke, whereas the other does not. But, as argued in the discussion above, the liberty of the post-2000 birth cohort is not restricted to an unjustifiable degree, and given the addictive properties of tobacco products, smoking is arguably incompatible with the notion of ‘liberty’.

 

Integrating TFG2000 into human rights systems

To summarise so far, we have argued that the TFG2000 proposal is consistent with human rights. It does not constitute a disproportionate interference with the rights to liberty, self-determination or privacy. Moreover, because of its support of the rights to life, health and a healthy environment, the TFG2000 proposal would in fact support a human rights-based approach to tobacco control. Such an approach is already being sought by the Human Rights and Tobacco Control Network and has been suggested previously, although not in the tobacco endgame context.12

What would comprise a human rights-based approach to a tobacco-free generation? States could make use of human rights reporting mechanisms, such as shadow reports made by local NGOs, to track their continued progress in the endgame. These reports could be used to tackle some of the practical difficulties (discussed in more detail below) in implementing TFG2000, such as compliance. Regular reports could also track the opinions of the public, to ensure they are properly educated about this new legislation and its reasoning.

 

Ethical issues related to public opposition

Although the TFG2000 proposal supports some fundamental human rights, groups of people may still oppose it; for example, those born after 2000 who want to smoke. Their line of argument is likely to be based on the human rights debate already discussed; that is, the policy is an unjustifiable restriction on autonomy, liberty or privacy, or promotes inequality among groups. Although TFG2000 does not directly restrict current smokers, they may also feel discriminated against or uncomfortable with the phase out. Arguments that oppose TFG2000 will almost certainly be supported and propagated by the tobacco industry. If the public opposes the phase out, it could result in low compliance, black markets and protest. These would hinder the success of the phase out. In Tasmania, the proposal already received some criticism, in which Tasmania was referred to as a ‘nanny state’.24 This line of thought may lead to further anxieties that the government will start on a slippery slope towards banning other unhealthy products.

Thus, the key to a successful phase out is a well educated public. People born after 2000 in particular should be educated on the reasoning behind the phase out and how it helps to realise fundamental human rights. This should be incorporated into education programmes for schools, parents and the public that look at different dimensions of tobacco control, such as human rights, the effects of passive smoke, and the influence of the tobacco industry. This approach is already being pursued in Singapore, where supporters of TFG2000 are actively working with schools. Education of the public should also clarify that TFG2000 is not a slippery slope towards phasing out other products, because TFG2000 is a measure designed to correctly reflect the relative hazard of tobacco compared with other substances.16 Alcohol, for example, is far less addictive than nicotine, which makes the controlled use of alcohol more tenable than controlled use of tobacco.

Still, even with good public support there will be a number of individuals who will not comply. One option is to increase government monitoring and enforcement of the new sales restriction. Another, less coercive option, is to study the public and increase support to help quit smoking, especially for those born after 2000. This will help to identify gaps in the strategy, and help specific subpopulations that need special attention. For example, if it is found that young people from specific schools or certain families have already started smoking before TFG2000 is legislated, and would otherwise have to resort to illegally obtaining tobacco, they could be offered cessation support programmes. Such programmes may consist of, for example, the supply of free medical therapies and counselling with peers and family members to help quit smoking. In Singapore, such therapy programmes have already been piloted, with good success.25

 

Conclusions and future directions

To conclude, we have argued that the tobacco-free generation proposal is compatible with human rights principles. It supports some fundamental rights, including the rights to life, health and a clean environment, and does not unduly violate the rights to liberty, self-determination, privacy or equality. If the above is correct, then the principal remaining obstacle for states wishing to implement TFG2000 will be in achieving sufficient public support and compliance with any resulting legislation. Education initiatives—particularly targeted towards those born after 2000—will thus be an important mechanism for raising public awareness and achieving the goal of a tobacco-free generation.

 

What this paper adds

This paper provides the first critical analysis of human rights considerations raised by a tobacco endgame proposal for a tobacco-free generation. While acknowledging that human rights rhetoric can be used to support both sides of the debate, we argue—through previous legal cases and human rights ethics debate—that Tobacco Free Generation 2000 is compatible with human rights principles, and may even form part of a successful human rights-based strategy for tobacco control.

 

Acknowledgments

We would like to thank Dr Ben Capps, Professor Graeme Laurie and four anonymous reviewers for their valuable comments in the preparation of this manuscript.

 

Footnotes

  • Correction notice This article has been corrected since it was published Online First. The Funding statement has now be added in.

  • Contributors Both authors wrote and conceptualised the paper, and checked final versions of the manuscript before each submission.

  • Funding This work was funded by the National Cancer Centre, Singapore.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:http://creativecommons.org/licenses/by-nc/3.0/

 

References

  1. Malone RE. Imagining things otherwise: new endgame ideas for tobacco control. Tob Control 2010;19:34950[FREE Full text]
  2. World Health Organization. Mortality attrubitable to tobacco2012http://whqlibdoc.who.int/publications/2012/9789241564434_eng.pdf (accessed 28 Mar 2013).
  3. Khoo D, Chiam YNg Pet al. Phasing-out tobacco: proposal to deny access to tobacco for those born from 2000. Tob Control 2010;19:35560[Abstract/FREE Full text]
  4. ABC News. Tasmania considers phasing out cigarette sales2012http://www.abc.net.au/news/2012–08–21/upper-house-moves-motion-to-ban-the-sale-of-cigarettes/4214016 (accessed 23 Oct 2012).
  5. The Guernsey Press. Guernsey may adopt similar cigarette ban to Tasmania2012.http://www.thisisguernsey.com/news/2012/08/29/guernsey-may-adopt-similar-cigarette-ban-to-tasmania/ (accessed 23 Oct 2012).
  6. Ministry of Social Affairs and Health. MSAH oversees tobacco control in Finland. 2010.http://www.stm.fi/en/welfare/substance_abuse/tobacco (accessed 23 Oct 2012).
  7. SmokeFree New Zealand 2025. Smokefree 2025. 2011.http://smokefree.org.nz/smokefree-2025 (accessed 24 Oct 2012).
  8. United Nations. The Universal Declaration of Human Rights. 1948.http://www.un.org/en/documents/udhr/index.shtml (accessed 7 Jan 2013).
  9. United Nations. International Covenant on Civil and Political Rights. 1976.http://www2.ohchr.org/english/law/ccpr.htm (accessed 7 Jan 2013).
  10. United Nations. International Covenant on Economic, Social and Cultural Rights. 1976.http://www2.ohchr.org/english/law/cescr.htm (accessed 7 Jan 2013).
  11. United Nations. Convention on the Rights of the Child. 1990.http://www2.ohchr.org/english/law/crc.htm (accessed 7 Jan 2013).
  12. Dresler CLando HSchneider N, et al. Human rights-based approach to tobacco control. Tob Control 2012;21:20811[Abstract/FREE Full text]
  13. Bradley A. Positive rights, negative rights and health care. J Med Ethics 2010;36:83841.
  14. Cook DGStrachan DP. Summary of effects of parental smoking on the respiratory health of children and implications for research. Thorax 1999;54:35766.
  15. Kit BKSimon AEBrody DJ, et al. US prevalence and trends in tobacco smoke exposure among children and adolescents with asthma. Pediatrics 2013;131:40714[Abstract/FREE Full text]
  16. Berrick AJ. The tobacco-free generation proposal. Tob Control 2013;22:i226.
  17. Tobin J. The right to health in International Law. Oxford: Oxford University Press, 2012.
  18. Wolf J. The human right to health. New York: W W Norton & Co., 2012Google Scholar
  19. Yamin AGloppen S. Litigating health rights: can courts bring more justice to health?Cambridge, MA: Harvard University Press, 2011.
  20. [2009] EWCA Civ 795; on appeal from R. (On the Application of G) v Nottinghamshire Healthcare NHS Trust [2008] EWHC 1096. For commentary see Coggon J. Public health, responsibility and English law: are there such things as no smoke without ire or needless clean needles? Med L Rev 2009;17:12739[FREE Full text]
  21. Council of Europe. The European Convention on Human Rights. 2010.http://conventions.coe.int/Treaty/en/Treaties/Html/005.htm (accessed 28 Mar 2013).
  22. Taylor v Attorney-General & Ors [2013] NZHC 1659.
  23. B v Waitemata District Health Board [2013] NZHC 1702.
  24. The Telegraph. Tasmania considers cigarette ban for anyone born after 2000. 2012.http://www.telegraph.co.uk/news/worldnews/australiaandthepacific/australia/9492504/Tasmania-considers-cigarette-ban-for-anyone-born-after-2000.html (accessed 7 Jan 2013).
  25. Kit PLTeo L. Quit Now! A psychoeducational expressive therapy group work approach for at-risk and delinquent adolescent smokers in Singapore. J Specialists Group Work2011;37:228 doi:10.1080/01933922.2011.606557

The original article can be viewed here at Tobaccocontrol.bmj.com.

 

Imagining things otherwise: new endgame ideas for tobacco control

Tob Control 2010;19:349-350 doi:10.1136/tc.2010.039727

EDITORIAL

Ruth E Malone

Correspondence to
Ruth E Malone, Professor of Nursing and Health Policy, Department of Social and Behavioral Sciences, University of California, San Francisco, 3333 California St Suite 455, San Francisco 94118, USA; ruth.malone@ucsf.edu

Contributors RM wrote the editorial.

Where are we going in tobacco control long-term, and how will we get there? This issue of Tobacco Control features three new contributions to the growing ‘endgame’ literature with possible answers to those questions: big-picture radical ideas that seek to propel the tobacco control movement more quickly towards a time when the global tobacco disease pandemic that began in the 20th century will be ended. Could the multitude of social structures and institutions that sustain the tobacco problem be unlinked? Could altered market forces—price controls, supply controls—render tobacco less attractive to those who profit most from continuing to addict new generations? Could there come a time when cigarettes—the most deadly consumer product ever made—will no longer be commercially sold? Can a stake someday be driven through the heart of the tobacco industry?

Endgame thinkers are the visionaries of the tobacco control movement. Early contributions to this literature, many of which were first published in this journal, included Borland’s regulated market model1; Callard, Thompson and Collishaw’s work on restructuring the industry so that it was incentivised to reduce consumption2; and calls for phasing out smoked tobacco products through various approaches.3–5 Others in this broad genre of work include Chapman’s6 call for licensing smokers, work on nicotine and other types of ingredient regulation to render cigarettes less or non-addictive,7 8 and other ‘big picture’ ideas.9 Increasingly, the idea that tobacco control is fundamentally a systems problem is becoming a part of global discussions.10 Major tobacco control programme successes also suggest that changing what tobacco use (and the tobacco industry) means is foundational to ending the global pandemic.11 12

In this issue, Gilmore and colleagues13 argue that regulating prices of tobacco through capping of manufacturers’ prices could reduce tobacco industry market power by eliminating manufacturers’ ability to disguise price increases and achieve higher profits. As they point out, in higher-tax western countries, the industry’s profits are increasing despite declining sales—profits that are then available to the industry to further promote tobacco use in the emerging markets of low-income countries.14 The thoughtful argument by Gilmore et al extends ongoing conversations about regulatory approaches to the tobacco market1 15 and offers an incentive for governments to act: an increased share of the money.

Khoo and colleagues16 propose a unique idea: end tobacco sales for those born after a certain date. Rather than focusing on preventing tobacco sales to minors, with the implicitly attractive ‘forbidden fruit’ message such approaches cannot avoid, the authors argue that their proposal to end sales to anyone born after the year 2000 would minimise immediate impact on stakeholders and allow time for transitions, while being entirely congruent with the tobacco industry’s assertions that they now seek to market only to existing smokers and not to youth. Interestingly, the authors’ preliminary work suggests strong public support for such an idea. Of course, Singapore is somewhat unique in its regulatory climate, but the idea offers a fresh perspective on ‘youth access’.

Addressing issues of supply is the focus of the proposal by Thomson et al17 for a ‘sinking lid’ on the commercial supply of tobacco, with quotas reduced gradually over a period of 10 years. Government-run auctions, such as those which have been used for other types of policies, would draw manufacturers to bid for a gradually decreasing amount of tobacco. If successful, they argue, such a system would increase the price of tobacco, contributing to reduced consumption. Combined with demand-reduction measures, such an approach could radically alter the tobacco control landscape within a country.

Could any of these latest big picture ideas really work? Perhaps not immediately, but they inspire us all to think beyond the next smoke-free ordinance or tobacco quitline. Perhaps they could not work in one country, but could be done in another—in one with more easily controlled borders, for example, in the New Zealand case, or in a country generally supportive of government regulation, as in the UK and Singapore.

It was through such visionary thinking that we began to understand that the suffering and death tobacco causes is not merely a problem of poor individual health behaviour choices, but of the rise of an entire industry focused on aggressively promoting deadly addictive products. It was through visionary thinking that we began to question whether breathing the smoke from others’ cigarettes might be harmful to non-smokers. It is visionary thinking, combined with skilled advocacy, that pushes governments to act more decisively to protect the public and to rein in the activities of tobacco companies.

Every person who becomes newly involved in the tobacco control movement, whether as an activist, researcher, programme planner or health professional, remembers that first moment of realising: it doesn’t have to be this way. Often, that realisation is coupled with the notion that cigarettes should just be banned, and incredulity that it has not already been done. Then, seasoned veterans explain the interlocking political, physiological, legal and economic webs that constrain such policy change. But the first step towards breaking through those webs is to rediscover our ability to imagine things otherwise.

The public may be more ready for radical changes than most policymakers recognise. Studies suggest there may be fairly strong support for ending tobacco sales.18–20 Earlier work drawing on tobacco industry documents showed that the industry’s own survey data from the early 2000s in the US suggested that a majority wished ‘there were some way to eliminate cigarettes’, supported banning cigarette advertising and felt that ‘the right and responsible thing for cigarette companies to do would be to phase out of the cigarette business.’21 Imagining things otherwise helps us see how to head towards where the public (and any rational person whose livelihood does not depend upon the tobacco status quo) already sees we should eventually go. But the tobacco control problem remains at its core a political problem: How to get governments to take bigger-picture actions to protect public health when a powerful industry opposes measures that threaten profits?

If we fail to exercise our moral imaginations to envision radical change, we are abandoning future generations to suffer and die from the mistakes of the past. We must instead continue to wrestle with, critique, develop and advocate for new visions of tobacco control. It doesn’t have to be this way.

 

Footnotes

  • Competing interests RM owns one share each of Philip Morris/Altria, Philip Morris International and Reynolds American Tobacco Company stock for research and advocacy purposes. She served as a tobacco documents consultant for the US Department of Justice in USA vs Philip Morris et al.

  • Provenance and peer review Not commissioned; not externally peer reviewed.

 

References

  1. Borland R. A strategy for controlling the marketing of tobacco products: a regulated market model. Tob Control 2003;12:37482.
  2. Callard CThompson DCollishaw N. Transforming the tobacco market: why the supply of cigarettes should be transferred from for-profit corporations to non-profit enterprises with a public health mandate. Tob Control 2005;14:27883.
  3. Daynard RA. Doing the unthinkable (and saving millions of lives). Tob Control 2009;18:5.
  4. Hall W, West R. Thinking about the unthinkable: a de facto prohibition on smoked tobacco products. Addiction 2008;103:8734[CrossRef][Medline][Web of Science]Google Scholar
  5. Gartner CMcNeill A. Options for global tobacco control beyond the Framework Convention in Tobacco Control. Addiction 2010;105:13[CrossRef][Medline][Web of Science]Google Scholar
  6. Chapman SLiberman J. Ensuring smokers are adequately informed: reflections on consumer rights, manufacturer responsibilities, and policy implications. Tob Control2005;14(Suppl 2):ii813[Abstract/FREE Full text]
  7. Benowitz NLHenningfield JE. Establishing a nicotine threshold for addiction—the implications for tobacco regulation. N Engl J Med 1994;331:1235[CrossRef][Medline][Web of Science]Google Scholar
  8. Hatsukami DKPerkins KALeSage Met al. Nicotine reduction revisited: science and future directions. Tob Control 2010;19:436Google Scholar
  9. Laugesen MGlover MFraser Tet al. Four policies to end the sale of cigarettes and smoking tobacco in New Zealand by 2020. N Z Med J 2010;123:5567[Medline]Google Scholar
  10. Borland RYoung DCoghill Ket al. The tobacco use management system: analyzing tobacco control from a systems perspective. Am J Public Health 2010;100:122936[CrossRef][Medline]Google Scholar
  11. Roeseler ABurns D. The quarter that changed the world. Tob Control 2010;19(Suppl 1):i315.[Abstract/FREE Full text]
  12. Chapman SFreeman B. Markers of the denormalisation of smoking and the tobacco industry. Tob Control 2008;17:2531[Abstract/FREE Full text]
  13. Gilmore ABBranston JRSweanor D. The case for OFSMOKE: how tobacco price regulation is needed to promote the health of markets, government revenue and the public.Tob Control 2010;19:42330[Abstract/FREE Full text]
  14. Callard CD. Follow the money: how the billions of dollars that flow from smokers in poor nations to companies in rich nations greatly exceed funding for global tobacco control, and what might be done about it. Tob Control 2010;19:28590[Abstract/FREE Full text]
  15. Jha PMusgrove PChaloupka FJet al. The economic rationale for intervention in the tobacco market. In: Jha P, Chaloupka FJ, eds. Tobacco Control in developing countries.Oxford: Oxford University Press, 2000:15374Google Scholar
  16. Khoo DKoong H-NBerrick AJet al. Phasing-out tobacco: proposal to deny access to tobacco for those born from 2000. Tob Control 2010;19:35560[Abstract/FREE Full text]
  17. Thomson GWilson NBlakely Tet al. Ending appreciable tobacco use in a nation: using a sinking lid on supply. Tob Control 2010;19:43135[Abstract/FREE Full text]
  18. Thomson GWilson NEdwards R. Kiwi support for the end of tobacco sales: New Zealand governments lag behind public support for advanced tobacco control policies. N Z Med J 2010;123:10611[Medline]Google Scholar
  19. Wilson NEdwards RThomson Get al. High support for a tobacco endgame by Pacific peoples who smoke: national survey data. N Z Med J 2010;123:1314[Medline]Google Scholar
  20. Shahab LWest R. Public support in England for a total ban on the sale of tobacco products. Tob Control 2010;19:1437[Abstract/FREE Full text]
  21. Yang JSMalone RE. ‘Working to shape what society’s expectations of us should be’: Philip Morris’s societal alignment strategy. Tob Control 2008;17:3918[Abstract/FREE Full text]

 The original article can be viewed here at Tobaccocontrol.bmj.com.

 

Stubbing Out Cigarettes for Good

BOSTON

PERHAPS no public official was as synonymous with the antismoking movement as C. Everett Koop, who died last Monday at age 96. Dr. Koop, who worked tirelessly to turn America into “a smoke-free society,” did not live to see that goal reached. But the rest of us have the power to make it happen.

Fewer than one in five American adults smoke, a share that’s plunged by about half since the 1960s — an achievement due, in some measure, to Dr. Koop’s antismoking crusade as surgeon general, from 1981 to 1989. Revelations in the 1990s about tobacco companies’ cover-up of smoking’s dangers also played a role. So have a host of other strategies that have included consumer taxes, minimum ages for cigarette purchases, restrictions on smoking in public spaces and programs to help people quit. Continuing on the same path, with some luck, we might be able reduce the smoking rate a little more.

But that would still leave us with a profound public health tragedy: cigarettes continue to kill more than 400,000 Americans a year and cost untold billions in health care spending.

To its credit, the Food and Drug Administration has tried more aggressive approaches, including a recent effort to require hard-hitting graphic warnings on cigarette packages. That proposal, already the rule in dozens of countries, has been held up in United States federal courts over concerns that the ads might infringe on cigarette manufacturers’ First Amendment rights. But even if implemented, more scare tactics would not go far enough.

What we need is an all-out push to reduce smoking rates to well below 10 percent. The notion is nothing new to tobacco-control advocates, many of whom gathered last week in Cambridge, Mass., for a conference on the governance of tobacco, sponsored by Harvard with support from the World Health Organization.

But outside of such academic meetings and journals, little has been said about two possible approaches that could have an immediate impact.

One involves federal action; the other, state or local action. Both are made possible by the Family Smoking Prevention and Tobacco Control Act, which President Obama signed in June 2009.

Under the act, the F.D.A. has the power to establish tobacco product standards including “provisions, where appropriate, for nicotine yields of the product.” The only limitation on this power is that the F.D.A. may not require that nicotine yields be reduced to zero. The law calls on the F.D.A. to apply public health criteria — “the risks and benefits to the population as a whole” — in designing its regulations. It also encourages the F.D.A. to create tobacco standards that will help existing users stop smoking and decrease the risk that nonsmokers will start.

The F.D.A. would be well within its authority to require nicotine content to be below addictive levels — an idea that originated with a 1994 article in The New England Journal of Medicine urging a nonaddictive nicotine standard.

Cigarette makers would lobby hard to block such a standard. But if the F.D.A. insisted on the change, and cigarettes ceased to be addictive, ample evidence shows that most smokers would quit or switch to less toxic nicotine products. Current nonsmokers, moreover, would be far less likely to become addicted.

Another part of the act affirms the authority of states and municipal governments to prohibit the sale, distribution and possession of — and even access and exposure to — tobacco products by individuals of any age.

This provides an opportunity for states, counties and cities to adopt the Smokefree Generation, a proposal by A. J. Berrick, a mathematics professor in Singapore.

The idea is simple: no one born in or after 2000 can ever be sold cigarettes.Under such legislation, which jurisdictions like the Australian state of Tasmania are considering, the vast majority of this cohort — the oldest are now 13 — would never begin smoking. It’s hard to imagine too many parents objecting, and it would be easy for retailers to enforce. In the United States, it would provide a useful focus for state and local public health officials to do something game-changing, rather than sitting on the sidelines waiting for Washington to act.

Critics will say that, even if a state or city passed such a law, would-be smokers could go to an adjoining one to buy cigarettes. But evidence suggests that border-crossing and smuggling would be minimal. States that have sharply raised their cigarette taxes, after all, have not only increased tax revenue but also reduced rates of smoking prevalence, even among nicotine addicts. Young people, who are generally not addicted (yet) and who tend not to have peers who smoke, are even less likely to chase cigarettes across state or county lines.

Some antismoking advocates who support existing approaches (smoking-cessation programs, higher taxes) fear that pushing for an “end game” — a smoking rate below 10 percent — is too ambitious. But then, banning smoking in restaurants, workplaces and bars was once seen as crazy, too. Sometimes, a little crazy goes a long way.


Richard A. Daynard is a professor of law at Northeastern University and president of its Public Health Advocacy Institute.
A version of this op-ed appears in print on March 4, 2013, on page A21 of the New York edition with the headline: Stubbing Out Cigarettes for Good.