Today’s issue of PLOS Medicine contains an interesting debate between Australia’s own anti-smoking paladin, Simon Chapman, and a professor Jeff Collin from Scotland, over whether governments should introduce a license for smokers. Chapman puts the case for a license, while Collin opposes it, and the debate is refreshingly free of jargon or paywalls, so quite accessible to non-public health types. I think the license is an interesting idea: basically, anyone who wants to smoke would be required to pay a fee to obtain a license, and no one without a license can purchase cigarettes. Licenses would be available for various quantities of cigarettes, and by registering the licenses with a fixed central database it would be possible to ensure that people could only consume within the licensed amount. Those who want to give up smoking could turn in their license and get a refund on all the years’ fees they’ve paid, plus interest. Meanwhile, the government would be able to accurately track smoking use statistics, which is very useful from a public health perspective. Chapman also suggests that, just like a driver’s license, one should be required to pass a test to get the license, thus in his words ensuring

that new smokers were making an informed choice, something the tobacco industry has long declared that it believes applies to smokers’ decisions

and guaranteeing that people who take up smoking have been required to inform themselves of its risks and of the difficulty in giving up. Chapman’s article also offers arguments to dismiss claims that a license would be intrusive, discriminate against the poor, or stigmatize smokers, and proposes a gradual lifting of the minimum age for acquiring the license in order to make numbers of new smokers less and less common. He compares the license with a license to drive or own a gun and, quite interestingly, with a prescription to take pharmaceuticals, which he represents as a kind of temporary license. On its own lights, it is quite a strong argument.

The opposing case by Collin takes a more structural, less drug-user-focused approach to the challenge of reducing smoking rates. He argues that we should continue to focus on regulating the pharmaceutical companies to combat what he calls an “industrial epidemic,” and says we should strengthen measures which

should centre on changing a system of manufacture and promotion of such harmful products centred on the corporation, an institution that is staggeringly ill-suited to such roles when viewed from a public health perspective

He suggests that further measures targeting users are both discriminatory and stigmatizing, and that increasing attempts to manipulate prices and cost barriers will punish existing poor smokers the most (and smoking, at least in developed nations, is a much bigger problem amongst the poor). This is a point that Chapman had disputed, but Chapman’s argument against it is at least partly based on dismissing these complaints as crocodile tears from the tobacco industry and its front organizations – of which I sincerely doubt Collin is a member. Collin argues, furthermore, that the idea of a tobacco smoker’s license is fundamentally illiberal, and grounds most extant bans of tobacco users‘ behavior in a liberal philosophical framework:

Smoke-free policies have been recognised and understood as unambiguously liberal measures rather than authoritarian intrusions on personal freedom. In advancing a case focused on the protection of non-smokers, workers, and children, such legislation conforms to JS Mill’s classic formulation of the harm principle in On Liberty: “(t)he only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others”

His argument, then, is that we should avoid anti-tobacco legislation that targets the users themselves, except to prevent harm to others, and focus instead on the source of the harm (the corporations). He even suggests that the imposition of licenses would represent a propaganda “gift” to the industry, and further punish poor people who smoke relative to the wealthier.

Overall I think Collin’s arguments are less coherent and consistent, but I am inclined towards his position on the issue. I think the license would probably be a good idea from a public health perspective, but represents a curtailment of individual liberty that is unnecessary. It doesn’t actually have any serious civil liberties implications – registering smokers is not the beginning of the police state – but it does shift the focus of efforts away from the source of the harm to its most immediate victims, and it does play a stigmatizing role. Collin also observes that the major goals of the Framework Convention on Tobacco Control (FCTC) are institutional, and in many countries have not been achieved, and it is better to work on systems for improving countries’ ability to meet those goals than to divert our efforts towards restricting users’ behavior. I agree with him on this point: many countries are a long way from a proper implementation of the basic goals of the FCTC – higher tobacco taxes, curbs on illicit tobacco, and indoor smoking restrictions, for example – and strengthening those countries’ ability to resist tobacco company money and marketing is a much better goal for anti-smoking activists. The reality is that smoking in the developed world is on the decline and will continue to do so, and as a result the tobacco companies are aggressively targeting developing nations. It is in those developing nations that activists should be fighting a battle for improved governance and institutional structures that will help those countries protect their health systems from this “industrial epidemic.”

The debate raises a related issue for me, which is: have some countries gone far enough in their anti-tobacco measures? Australia, for example, having now passed plain packaging laws, has pretty much made smoking as unattractive and difficult as it can do without actually banning it. Should we stop there? The reason this is an issue for me is that I play a violent sport, and I recognize that violent sports represent a deliberate choice by people to take risks with their health in pursuit of a certain pleasure. So does drinking to get drunk, and so does casual sex, both activities of which I approve. At some point we have to recognize that people have the right to trade health for fun, and although that doesn’t give people carte blanche to, for example, go surfing in a frankenstorm or dance naked in front of lions, it does mean that at some point we have to draw a line beyond which public health measures must stop. From a public health perspective, so long as anyone is smoking, “more needs to be done.” But from a civil liberties perspective, at some point the barriers to smoking and anti-smoking education are such that we can safely say people who take up the habit know the risks and are suitably reminded of them that there is no reason to further intrude on their personal decisions. Have some developed nations reached that point? For Australia at least I’m not sure there is much more that can be done except to introduce a license, or introduce the rolling bans mentioned in Chapman’s article. Do we need to go that far, or is the current status quo sufficient? Should the anti-tobacco lobby in Australia be relaxing their national attention simply to being vigilant against new tobacco industry efforts, and instead begin focusing more of their energy on the other countries in the West Pacific where smoking remains a serious and growing problem?

There comes a point where you have to accept that the activity harms no one else, the person engaged in it is willing and aware of the risks, and the activity is suitably challenged in everyday life that they must be committed and really want to do it. At that point, perhaps public health organizations need to step back, and instead of further restricting the behavior, defend the right of those engaged in it to do so, and to get healthcare for the problems it causes. This is what we do now for mountain-climbing and rugby, two very dangerous but well-respected activities. I think it is possible that in some developed nations, smoking has reached that point, and maybe in those countries enough has been done.