New Zealand already has some of the highest tobacco taxes in the world, and now some campaigners are calling for them to raised much further. But how effective would that be? Not very, say tobacco-control experts Marewa Glover and David Sweanor. What’s needed are solutions that empower smokers, not punish them further.
The government’s new plan to allow a range of safer alternatives to smoking tobacco, including snus and heat-not-burn products, in addition to electronic cigarettes, shows that New Zealand is once again moving towards leading the world in dealing with the horrendous carnage caused by cigarette smoking. Associate minister of health Nicky Wagner said the plan, which will establish a pre-market approval process for smokeless tobacco products, is part of a “forward-looking approach” to reducing smoking.
New thinking is needed because the old tobacco control strategies, based largely on coercion, have run out of puff. Yearly tax hikes on tobacco, mass media campaigns encouraging the public to shame and shun people who smoke, and bans on smoking – and increasingly on smokers themselves – are not getting us where we need to be. Smoking rates among Māori, Pacific Island and lower socio-economic groups have remained stable for the past nine years.
New Zealand’s extremely high taxes on tobacco (amongst the highest in the world) and the rise in aggravated robberies for tobacco, combined with genetic and neuroscience work on nicotine dependence, suggests there could be a tipping point at which coercion-based policies start to be less effective. Coercion in pursuit of a public health goal can start to look like the smiting of sinners. In this case, those ‘sinners’ already want to ‘repent’ – they want to quit smoking but are not empowered to do so.
A natural tendency when faced with measures that are not accomplishing all that we had hoped is to double-down, to do more of the same. The plan by anti-smoking group ASPIRE2025 launched this week recommends doubling the tax on tobacco, restricting the number of cigarette retailers, and lifting the age of purchase. All measures that will make tobacco more expensive and harder to get, at least legally, and will further marginalise a great many already disadvantaged people who are victims of cigarette dependency. Maybe it is time to think creatively about alternatives instead.
So how could we increase the pace towards Smokefree 2025 (the government’s goal to reduce smoking to under 5% of the population by 2025) without increased collateral damage? Shifting from a ‘quit or die’ ultimatum to a harm reduction approach is critical. This recognises that the problem is not the nicotine, but the inhalation of smoke. While nicotine can be addictive, it is the toxic brew of inhaled smoke that causes the disease. Supporting people to switch to safer alternatives could make cigarettes obsolete, which would be a public health revolution on par with the eradication of smallpox.
But as any good revolutionary knows, for a public health revolution to succeed the people need to be on your side. In this case, ‘the people’ are the smokers we purport to care about, but who at the moment feel unfairly judged, belittled and marginalised. To win back their trust we need to respect them and acknowledge the social determinants keeping them smoking. We need to address smoking within the context of people’s lives and give preferred alternatives – not deal with nicotine use in isolation from their other social and health concerns. In this time of alternative facts, we need to deal in the truth, not just comforting beliefs.
So, what if we did the sorts of things that public health history and ethics should drive us to do? What if we promoted compassion and empowerment for those who smoke? The promise of better smoking cessation assistance certainly helps, as does the promise to facilitate a far wider range of low risk non-combustion alternatives to cigarettes (various forms of smokeless tobacco, vaping, heat-not-burn, and hopefully many other things as they are developed). But we can do more.
Rather than the government’s suggested cautious approach, why not a heroic one? Thousands of New Zealanders and six million people worldwide are dying annually from inhalation of cigarette smoke, and those global numbers are going up. How about facilitating getting low risk products onto the market as fast as possible? What about ensuring these low risk products are easily accessible to smokers, for example by coupling switching support with incentive vouchers? What about clear tax and marketing advantages for the much less hazardous products that can replace cigarettes? Most immediately, what about a vigorous campaign to tell the public the truth about the enormous differences in risk between cigarettes and already existing alternatives?
We don’t need to punish those we seek to help. We need to empower them. We need to partner with them to facilitate better health. Truthful information, better options, greater accessibility, fast approvals and rigorous monitoring of the impact. The faster New Zealand moves on empowerment of smokers, on measures that uplift peoples’ mauri (life force) instead of crushing it, the faster we can set a precedent here that can help avert the world’s predicted one billion smoking-caused deaths this century. As national goals go, doing simple but visionary things that can avert a billion deaths is a pretty uplifting choice.
Marewa Glover has worked on reducing smoking in New Zealand for 25 years. She is an associate professor in Public Health at Massey University, chair of End Smoking NZ and a 2017 Women of Influence finalist.
David Sweanor is an adjunct professor at the Faculty of Law and the Centre for Health Law, Policy and Ethics at the University of Ottawa. For over 30 years he has helped develop tobacco-control laws in Canada and other countries, including advising on New Zealand’s 1990 Smoke-free Environments Act. He was the recipient of Ottawa’s Outstanding Individual Philanthropist award in 2016.
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