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.
Compromise and Conceit 
November 18, 2012 at 7:17 am
Once the impact on other people’s health is eliminate or minimised (i.e. can’t smoke indoors, etc) then the only real public argument to make against smoking is a cost one, namely “You’ll get cancer and society has to pick up the bill.”
As you point out this objection actually applies for activities such as mountain climbing and rugby.
This opens the door to either a) Public healthcare should not cover high risk activities or b) licensing of everything that carries higher degrees of risk.
The issues here are, for A: How do you identify the damage as being associated with the risk and how do you expect people who are excluded to deal with it (i.e. is dying on the street the official suggestion to them?)
For B: Seriously? License everything?
Given the implementation costs and the sheer assault on personal liberty and privacy we have to determine whether to draw a line before reaching those points.
I agree with your stance that the current measures are pretty much the best we can hope for. We can include taxes in the good associated with the risky activities (i.e. cigarettes and climbing equipment) thereby defraying the public cost without incurring the downsides of licensing or denying people healthcare in their hour of need.
November 18, 2012 at 4:45 pm
One missing element in such debates is that smoking (like most other drug use, and many other risky acivities) is heavily influenced by the number and kind of people doing it. In my youth, for instance, there was little stigma and almost no penalty attached to driving under the influence. Not now. Likewise with smoking, Mych of the anti-smoking effort has gone into making it inconvenient/uncool, so that reductions in use feed back into further reductions.
Latest step in Australia is banning smoking in cars with kids. No visible kickback so far, so this makes it even less convenient. Rates have dropped at a fairly steady 1-2% a year, and are now around 17%, so in a few years will be very much a minor habit.
November 19, 2012 at 11:07 pm
Actually Peter T, though it is not often openly stated in mass media, I think most people involved in Tobacco Control are aware of the role of peers in mediating smoking commencement and cessation, and the value of social normalization is recognized. In general though the framework convention on tobacco control tries to avoid promoting any measures that would encourage stigmatization – smoking bans, for example, are described in the convention entirely in terms of their role in protecting people from exposure to secondhand smoke and take only one paragraph, while taxes get about five. Also, wherever possible public health interventions need to be based on evidence, and the evidence for things like tax rises is much stronger than the evidence for peer effects.
Paul, actually a lot of dangerous activities are effectively licensed. Rugby, for example, even at an amateur level, generally takes place either in schools or in competitions, and competitions have to live up to certain basic standards if they want insurance or to be allowed to use public grounds. Similarly amateur martial arts generally now require that competitions take place within an authorized framework, and sparring trainers now basically need to be licensed by the government – which in turn means that even the most amateur level of fighting sports are licensed. It’s far from a perfect system, and the players themselves aren’t licensed at an amateur level, but it does have a role in monitoring and managing health risks. Insurance issues also play an important role there. So the idea of licensing “everything” isn’t entirely out of whack with reality.
A possibility that Chapman overlooked in his argument for a license was using a free market, or cap-and-trade, type model to restrict smoking. So the government could act as an exchange for the sale of licenses, and themselves sell a certain number every year, with those giving up smoking selling their licenses directly to other smokers through the exchange, and the government using the price signals from those sales to set its own license prices. Then each year it could sell less licenses, available on a first-come-first-served basis, and anyone who doesn’t get one has to purchase them on the free market from quitters. Then over time as the price for new entrants goes up (because the government is selling less licenses), the financial incentive for existing smokers to quit would grow, since they’re selling their license on the marketplace. This cap-and-trade mechanism could be used to simultaneously restrict numbers of new smokers, and to give increasingly large incentives to existing smokers to give up.
I suppose the down side of this could be that smokers would be encouraged to see their license as an asset – they could sell it for $1000 this year or sit on it for five years and sell it for $1500. But since a) their decision to become smokers indicates they have a very high discount rate, this is unlikely to be a palatable decision for them, and b) they had to receive full education about the dangers of smoking in order to get the license in the first place, so there’s no reason to think they would keep smoking after they decided to treat the license as an investment, I don’t think this is an issue. All the better actually if they’re withholding a license from the market as an investment, and giving up smoking in the interim.
Of course the other risk is that an investment company would buy up all the licenses and sit on them. But this could be the first case in history of a vulture speculator genuinely benefiting the community, since they’d kill smoking in a whole cohort of new smokers. It would take some very delicate modeling to work out the best number to buy and the best time to sell, since if you wait too long the price will go so high that no one will want to bother becoming a smoker.
The thing I like most about the licensing idea is the requirement for everyone to pass a test to get it. I think that is a really pesky turnaround on the rational consumer idea, and I wonder how many potential license holders would persist with their “investment” if they had to take one of those tests. If they continued to have a high take up rate, that would be the final nail in the coffin for “education” as a form of health promotion!
November 20, 2012 at 10:43 am
Faustus
I sat for a time on one of the Australian high level policy committees on illegal drugs. The people around the table were very aware that no single element of policy worked in isolation, and that elements that had low measurable effect (eg warnings and ad campaigns) were nonetheless critical to the success of other elements that would more measurably effective. So ads set the public tone that made for wider acceptance of price hikes and usage restrictions, while public awareness of treatment options again gave people the idea that the policies were not simply punitive. And if these produced lower take-up rates, that made the next round of measures easier to implement. I think we are a way off public acceptance of a licensing regime, and there is probably no need for one while rates keep going down.
November 20, 2012 at 11:13 am
”So the idea of licensing “everything” isn’t entirely out of whack with reality.”
There are varying options here that (sort of) boil down to licensing directly and licensing/taxing indirectly. A tax on cigarettes or a fee for a rugby club to use a public oval are means of collecting funds indirectly to cover risks. They don’t impact the user at the point of use, but do have an indirect effect that trickles down. This appears to be an easier system to setup and manage.
By contrast, a system of licensing at the point of use would be more like tickets on public transport. It can work when in a controlled environment and well run (i.e. most cities public transport) or it can be a classic example of fighting a vain rear guard action against the free rider problems (i.e. Melbourne’s public transport).
To say that these two types of control are both licensing is a stretch/simplification.
An example of how rorting of licensing can occur is if there is some sort of sliding scale of cost for the license. If the first 5 cigarettes are free and then every 5 after that have an increased cost then some smokers are going to game the system by asking friends to get the minimal cigarette allowance and then pass it on. A flat indirect license charge (i.e. the current cigarette tax) minimises this. A direct charge can’t easily be applied at the point of use (i.e. outside the pub when chatting to the cute red head) so it applies at point of sale (which, as I described, can be open to other failures).
On cap and trade smoking, I can guarantee that if you were to introduce it I would buy a license. I don’t want to smoke but I do want to hold an appreciating asset desired by desperate addicts. I’ll also buy any heroin dealerships that the government feels like legalising. Shares in your vulture speculator sound like a winner to me.
From another angle, I don’t think cap and trade would work as your dealing with a luxury good, a fixed supply and no way of using market forces to drive efficiency. It’s not like cap and trade is going to lead to “low cancer” cigarettes comparable to low carbon technology as the current tax regime should already be incentivising this if it were possible [1].
[1] I’m confident that if any company thought they could do it, they would then they’d demand a cut in taxes for their product and brand it as the healthy alternative. It’s basically what the nicotine alternatives shaped as puffers/sticks already do.
November 24, 2012 at 7:45 pm
Isn’t licensing a kind of registration?
In some countries heroin addicts have to be registered to get their prescription for drug of addiction. I’m no health expert but I understand that the social outcomes are at least as good as those countries where there is no licensing of those dependent on that particular drug of addiction.
It seems to me that if we extend licensing to other drugs of addiction we have a control other than the blunt pricing mechanism. Indeed in Australia tobacco addicts might have access to PBS subsidies and safety nets. Which would be nice given that those on low low incomes – and the mentally ill – are disproportionally in the thrall of tobacco addiction.
I’m not sure licensing heroin addicts in Australia would be such a good idea. If only because a certain kind of entrepreneur would say, “It’s a legal product; why can’t we advertise?”
November 25, 2012 at 8:39 am
“It’s a legal product; why can’t we advertise?”
Surely the answer to that would be “Feel free to build up a brand presence, but I’d look at the smoking lobby’s results before I got too attached to those brands.”
Maybe the next logical step for Australia is to assign every cigarette an ugly sounding colour, then change all the names to “Cancer stick “. So ordering Winnie Blues would become “I’ll have a cancer stick puce, please.”
November 27, 2012 at 7:25 pm
Syd, I think the licensing aspects of registering heroin users are based in a more complex social and health problem. Heroin use has consequences that extend beyond the user themself, through crime and social order problems and the spread of infectious disease; furthermore, the health effects of heroin use aren’t a slowly-accruing long-term phenomenon, but an immediate problem demanding immediate management. We register heroin users and get them into treatment so that we can keep them alive until they stop; smokers will be alive for a long time with no ill effects, giving us lots of alternative ways to manage their behavior. So the parallel falls apart there, I think.
I don7t see any reason why the existence of a license should lead to companies being allowed to advertise a product.
An alternative I’ve often thought could be considered would be to require companies that sell tobacco to buy a license, just as bars do. There could be on- and off-license rules, so that a bar could choose to purchase a license to allow smoking onsite, or to have a smoking room. Then you could just fix the price of the license to cover the expected health costs of second hand smoke to employees, and sell the license with strict rules about employee relations (hazardous workplace premiums, limits on working hours, etc.) This seems like a liberal alternative to smoking bans.
November 28, 2012 at 9:21 pm
faustusnotes, I agree that heroin and tobacco are two very different products, with different consequences for their users and society.
But let us try a counterfactual. What if, owing to different enthusiasms by wowser groups in the past, it is heroin that is legal (albeit frowned upon) and tobacco which is banned?
Many smokers, being compliant citizens, quit. Those that cannot pay a premium for the product, owing to higher distribution costs and monopoly rents charged by criminal cartels. A pack of 25 can cost between $50 and $150 depending on supply and how efficient the Drug Squad and Customs are in constricting said supply. Two packs a day is a habit that is out of reach of all but stockbrokers, housebreakers and prostitutes.
All smoking is driven indoors where it is out-of-sight from others.
What of heroin? The price comes down – it’s just the cost of manufacture, shipment from Tasmania and a profit that is merely the ordinary return on capital. For reasons of health and safety every $25 package (about a week’s supply for a normal habit) comes with the necessary number of sterilised fits. Disposal facilities are even more widespread than in our timeline – you would no more see a used syringe in a park than you would a discarded tampon applicator.
In this alternative universe is tobacco seen as a bigger health problem than heroin? Are the people of this other timeline necessarily more misinformed than we are?
November 29, 2012 at 7:06 am
” Disposal facilities are even more widespread than in our timeline – you would no more see a used syringe in a park than you would a discarded tampon applicator.”
I’m not sure this would hold true. I have limited information on the subject but my understanding is that using a tampon doesn’t make you high as a kite. Nor is tampon insertion prevelent in parks, despite it’s legal status (again, noting I’ve bugger all info on the topic). By contrast both smoking and heroin use do occur in parks.
This suggests that there are other factors at play here.
December 1, 2012 at 8:04 pm
The stats on heroin use are sobering. Around one in four of those who try heroin will become dependent. Of every five of these, within 15 years, two will be dead, two will be on some form of managed care, and one will have kicked the habit. License regimes for heroin manage the social and health problems of people who are in the last stages – it’s a form of palliative care (and well worth it). These stats are much the same regardless of treatment and enforcement policies.
In places where heroin is effectively “legal” (that is, readily available and law enforcement is ineffective), such as the Shan States, northern Pakistan or north-west Afghanistan, usage rates are several times higher than in say Australia, but users still end up living on the social margins and have high death rates. For all its problems, tobacco seems to be a much more socialisable drug.
December 1, 2012 at 8:20 pm
Also, in places like Australia, heroin doesn’t have a large and well-established body of users, and corporate actors with an interest in maintaining sales. This makes it much easier to prohibit, since none of the commercial victims of its use have the ears of the people in power. In contrast, alcohol and tobacco have powerful existing lobby groups, and are used by the police. Banning them is essentially impossible.
It’s worth noting that the packaging ban started today. Will the world end? I think not!
December 2, 2012 at 10:34 am
Heroin did have a fairly large – and certainly well-established – body of users at the height of the heroin “epidemic” (best estimates at around 130,000 dependent users). A fortuitous combination of law enforcement policies and successes inhibited supply, whereupon the drop-out rates mentioned above came into play, and the cycle went into reverse (lower supply – lower rate of initiation coupled with high rate of attrition – less incentive to supply and so on). Now down to around 30,000.
My experience is that banning something used by 16% of the population is recognised as difficult if not impossible (see tacit relaxation of enforcement against majuana as rates rose).