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Could a scheme for licensing smokers work in Australia?

Roger S Magnusson and David C Currow
Med J Aust 2013; 199 (3): 181-184. || doi: 10.5694/mja13.10229
Published online: 5 August 2013

Summary

In a recent article in PLOS Medicine, Chapman argued for the mandatory introduction of a licensing system for adult smokers,1 using age- and identity-verifying licences based on smart-card technology. Producing the licence would be a precondition to all cigarette purchases by adults who opted, after a 12-month phase-in period, to continue smoking. Retailers would be required to reconcile all stock purchased from wholesalers against a digital record of retail sales to licensed smokers. Together, these requirements would create a robust incentive for retailers to comply with laws that prohibit tobacco sales to children2 and would enable creation of a database of smokers and their cigarette purchases. These data would be extremely valuable for improving understanding of smokers’ behaviour and monitoring the effectiveness of smoking-cessation initiatives.

We agree with Chapman that a smokers licence could be an important next step for reducing smoking rates, but we differ about the optimal design features of such a scheme. In our view, a smoker licensing scheme needs to be as simple as possible and to focus on two clear goals:

We evaluated the key design features of Chapman’s proposal in terms of their relevance to achieving these objectives (Box). We would eliminate the non-core design features, resulting in a no-frills licence that would be easier to implement and administer, and easier to justify in light of the goals of the scheme. The non-core features described by Chapman included various licence categories based on a maximum purchase quota chosen by the smoker, a pre-licence test of the smoker’s knowledge about smoking risks, and a financial incentive for surrendering a licence by quitting smoking.

Reducing unlawful tobacco sales to children

It is an offence in all states and territories to sell tobacco to people who are under 18 years of age. However, these laws are widely flouted. The 2010 National Drug Strategy Household Survey found that 2.5% of adolescents aged 12–17 years were daily smokers; another 1.3% smoked less frequently.9 While most adolescents obtained cigarettes from friends or relatives, 31% of the tobacco smoked by adolescents was purchased from retailers or directly over the internet.9 A 2011 survey of Australian secondary-school students aged 12–17 years found that 50% of 17-year-old smokers and 21% of 12-year-old smokers believed it was “easy” or “very easy” to purchase cigarettes themselves.10 In an environment where nearly a third of tobacco smoked by adolescents is sourced through illegal sales by tobacco retailers, the requirement for retailers to verify that every pack sold is purchased by an adult is long overdue. Even if a smokers licence results in some increase in secondary purchasing by adults for children, the overall reduction in access by minors would be substantial and could eclipse any other single tobacco control measure currently under consideration.

In 2010, the average age for smoking initiation among people aged 14–19 years was 14.9 years.9 Reducing tobacco purchases by adolescents is central to the future course of the current epidemic of tobacco-caused disease, since most adult smokers began to smoke as children or adolescents, at a time when they were unable to purchase tobacco lawfully.

The administration of a smart-card licence would require all tobacco retailers to be identified and licensed.11 Four jurisdictions (South Australia, Western Australia, Tasmania and the Australian Capital Territory) already administer tobacco retail-licensing schemes. A retailers licence shares the goal of eliminating supply-side retailer violations, by making compliance with age-based restrictions and other controls a condition of the licence to sell tobacco products. However, the requirement for adults to present a licence when purchasing tobacco is a demand-side response that would complement supply-side controls, since it would enable health departments to audit tobacco retailers at any time. Tobacco retailers subjected to audit would be required to provide a reconciliation between the stock of tobacco supplied to them by wholesalers and the electronic data trail of retail sales to licensed adults.

In order not to undermine the integrity of a point-of-sale licence verification scheme, Australia would be wise to follow the United States, which, for different reasons, has substantially curtailed internet and mail-order sales by making tobacco products non-mailable matter through the US Postal Service, with limited exceptions.12 Non-US Postal Service carriers are permitted to accept internet orders for tobacco products and to send parcels containing tobacco, provided that the purchaser’s identity is verified through an identity authentication database at the time the order is placed and an adult verifies his or her identity with photo identification at the time of signing to accept delivery.12 In Australia, if mail-order and internet tobacco sales are permitted, they should be limited to adults in genuinely remote areas who present their smokers licence on collection. The integrity of these controls would be further enhanced by prohibiting direct, small-scale imports of tobacco products into Australia.

It has been estimated that in Australia in 2005, tobacco companies received over $15 million from children, while retailers received $9 million.13 The 2010 National Drug Strategy Household Survey found overwhelming support from the Australian public for stricter enforcement of laws against supplying minors (89% of those surveyed), and strong support for a licensing scheme for tobacco retailers (70%).9

Objections to a smokers licence
“But it’s a legal product”

One of the enduring achievements of the tobacco industry is that, despite four decades of tobacco control, there has been little disruption to the underlying cultural assumption that a product — even a product that was responsible for 100 million deaths in the 20th century and, if current trends persist, will be responsible by 2030 for 10 million deaths each year21 — should be traded on market principles. We agree with Chapman that this notion needs to be quashed.

That does not mean, however, that tobacco should be banned, as some have advocated.22 Prohibiting tobacco at the present time would be likely to encourage a black market. Calls for a ban on smoking, and other “endgame scenarios”, are a distraction from the next generation of tobacco control policies — the constraints on supply and demand — that need to remain the focus as we work towards achieving a daily smoking prevalence that is a fraction of the current rate.

Stigma

Perhaps the most significant objection to a smokers licence is that it would exacerbate the stigmatisation of smokers. Collin, in his article answering Chapman, fears that smokers would feel they were being treated like “registered addicts”, and that, given the social gradient of smoking, a smokers licence would also amount to “censuring the poor”.24 He alludes to an important challenge for governments: tobacco control strategies have not been equally successful across all socioeconomic strata, and those who continue to smoke are more likely to have lower levels of education and income.9 This means that as smoking rates fall, all smoking-cessation interventions — especially those that aim to assist disadvantaged smokers — are at risk of being framed as “targeting the poor”. There is room for debate about the point at which policies intended to reduce socioeconomic disparities in health, such as higher tobacco taxes, cease to further this objective, and simply exacerbate poverty.25 On the other hand, if we want to make progress in reducing disparities in health, it is important not to point to the disparities themselves as grounds for doing nothing. It is also important for public health policies not to undermine the dignity of individuals, including those who wish to smoke. However, a smokers licence protects choice: it does not impose a smoke-free lifestyle on adults who cannot, or who choose not to, give up.

The bottom line

Australia remains a leader in tobacco control, having recently implemented the Tobacco Plain Packaging Act 2011 (Cwlth)26,27 and extended the Tobacco Advertising Prohibition Act 1992 (Cwlth) to ban tobacco advertising on the internet or using telecommunications devices. Other priorities have been signalled by the National Preventative Health Taskforce.28 They include:

There is evidence that the density of tobacco retailers in Australia is higher in areas of socioeconomic disadvantage,29,30 even after controlling for smoking prevalence.29 Research also suggests an association between the proximity of tobacco outlets to schools and adolescent smoking.31,32 Creating legal mechanisms to give local councils greater control over the location and density of tobacco outlets is a priority for tobacco control33 that could help to reduce an environmental contributor to socioeconomic health disparities.34

Once we get beyond the “shock of the new”, it is difficult to identify anything about a smokers licence that is particularly offensive or demeaning, given what we know about smoking. The concept of a smokers licence balances the reality of mass demand for tobacco in Australia against the fact that smoking is highly addictive and leads to the premature death, by about two decades, of one in two long-term smokers.35

Evaluation of key design features of Chapman’s smoker licensing scheme1

Possible advantages


Possible disadvantages


Core features

Smart card licence: adults wishing to purchase tobacco products must present a smart-card licence at point of sale to electronically verify their age and identity*

Individual patterns of tobacco purchases traced; data used for individualised quitting support

Data trail allows verification of whether all tobacco supplied to retailers was sold to adults

Data trail allows better understanding of smokers’ behaviour (eg, in response to retail price variations and discounts)

Data trail allows detailed tracking of smokers’ responses to smoking cessation programs and initiatives

Data trail allows monitoring of the impact of cigarette price discounting by retailers

Retail licensing controls extend accountability throughout the tobacco supply chain, from growers, dealers and manufacturers to retailers and adult smokers

May cause some smokers to feel they are “registered addicts” and add to the stigmatisation of smokers

Creates a historical database of adult smokers; recent activation of the licence implies current smoking. Privacy laws need to ensure data are protected and used only for authorised purposes

Scheme would need to cover pipe tobacco, cigars and waterpipes or risk creating market distortions in favour of these products, all of which share a significant risk profile3-5

Non-core features

Licence categories: licence holders would self-select into one of several categories of smoking intensity; licences with a higher purchase limit would cost more

Pre-commitment to a daily maximum would highlight to smokers their actual consumption; may motivate some smokers to quit or reduce consumption

Higher cost of licence with a higher consumption limit may encourage moderation

Some may overcommit to avoid the risk of running out of cigarettes, to moderate the impact of limits on bulk purchases, or to acquire flexibility to purchase tobacco for other people (eg, non-licensed smokers)

Purchase limits: licence holders could only purchase 2 weeks’ supply at a time, based on their daily maximum

Limiting bulk purchases may create a disincentive to sharing cigarettes, and to the social marketing of tobacco use

Some people (smokers and non-smokers) might choose a high licence category and onsell cigarettes in a way that undermines purchase limits

Annual renewal of licence

Cost of renewal would not be trivial; this may encourage some smokers to quit

Annual renewal would disproportionately affect people on low incomes (who smoke more and are more sensitive to price increases)

Annual renewal fee is an additional economic barrier to purchasing cigarettes; this may encourage onselling and result in hidden consumption, undermining the value of data obtained at point of sale

Licence surrender refund: smokers could permanently surrender their licence to receive a refund of all licence fees previously paid, with compound interest; after a 6-month “cooling off” period, the licence could not be taken up again

Refunding previous licence fees could provide a significant financial incentive to quit

Smokers who relapse after licence surrender could not lawfully purchase tobacco at retail and may resort to direct imports, informal sales or the black market

Smokers may strategically surrender their licence for a cash bonus, thereafter purchasing tobacco informally from other smokers (or non-smokers) who have a high licence limit

The licensing scheme would not be self-funding if smokers could claim a refund of all licence fees previously paid

Temporary licences available for purchase by international travellers verified as adults at ports of entry

Adds to overall complexity

Knowledge test: to qualify for a licence, adults must pass a knowledge test about the risks of smoking

Risk-minimising, self-exempting and rationalising beliefs are well recognised features of smoking behaviour.6 Most smokers know smoking is unhealthy, but are not well informed about the magnitude of their individual risk and the full range of possible harms. A pre-licence knowledge test may encourage some not to take up smoking; it also ensures that the decision to smoke is more informed

Consistent with tobacco industry preferences, the knowledge test requirement frames tobacco use as a “risky choice by informed individuals”, diverting attention away from the industry’s conduct

Shifts the focus away from supply-side controls (on tobacco manufacturers and retailers) to demand-side controls (on individuals)

Could be used in legal proceedings to exempt the tobacco industry from liability for harm caused by its products, based on the smoker’s “voluntary assumption of risk”7,8

Minimum purchasing age: over time, the minimum age for obtaining a licence to purchase tobacco might increase above 18 years

Adult smoking rates may fall significantly if the minimum age for eligibility for a licence is increased up to the age (eg, 23 years) after which it is unlikely that a person will take up smoking

Adults who become addicted to smoking while still ineligible for a licence will be forced to purchase tobacco informally (eg, through onselling, direct imports)


* Could be implemented nationally under Commonwealth law, by states and territories acting together, or it could be trialled by individual states. Additional regulations, including a ban on online and mail-order tobacco sales, would be best implemented at Commonwealth level. Data security and privacy laws to protect data generated at point of sale could be implemented at either Commonwealth or state levels.


Provenance: Not commissioned; externally peer reviewed.

  • Roger S Magnusson1
  • David C Currow2

  • 1 Sydney Law School, University of Sydney, Sydney, NSW.
  • 2 Cancer Institute NSW, Sydney, NSW.



Competing interests:

No relevant disclosures.

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