Paper to a Seminar at the Department of Oncology, King Faisal Specialist Hospital, Riyadh, on Tuesday 10 Dhu Al Qadah (15 February 2000).
Keywords Health, Regulation & Taxation
There is a huge body of evidence that the smoking of tobacco shortens life expectancy and damages health before that. Many western nations, including New Zealand, have therefore taken measures to reduce and eliminate smoking. They have been largely successfully both in terms of reducing the quantity of tobacco consumed and tobacco induced morbidity and mortality, although there is a considerable lag between the reduction in consumption and the reduction in disease. In another group of countries, typically the poorer ones, tobacco consumption levels are low in most social groups. However there are fears that with increases in discretionary incomes and more persuasive marketing by the international tobacco companies smoking will increase to levels as high as the peaks that occurred recently in Western nations a generation ago. Between these two groups of nations are those whose smoking has already reached peak Western levels, but have not yet taken measures to reduce them. They are, in effect, a generation behind the Western nations in terms of when they began smoking and also when the smoking induced disease becomes evident. The best documented is Japan, but some Middle East countries may belong to this category.
The differences between the West and Japan arise from smoking becoming widespread in the West in the 1930s and 1940s (moreso among men than women), whereas the Japanese smoking uptake has been a post-war phenomenon.(2) Figure 1 illustrates the difference between Japan and Western Nations. British lung cancer mortality rates among males peaked in the early 1970s, and now are about half the level of that peak, the Japanese male mortality rate has been increasing steadily since the 1950s, and now surpasses the British rate. The expectation is that in 2015 it will still be increasing and is expected to be about four times that of the forecast British rate.
Note that while lung cancer is the best indicator of the smoking disease, smoking exacerbates heart conditions, and rates of cardiac mortality from smoking often exceed that of lung cancer. This medical phenomenon has that policy consequence that while often the most vigorous medical lobby for eliminating tobacco smoking is oncologists (supported by public health specialists), cardiac physicians have a real interest in the policy too. For instance, in New Zealand one of the earliest, feistiest and most effective opponents of smoking was a cardiac physician, Sir David Hay.(3) A key element in the success of the anti-tobacco campaign policy in New Zealand has been that it has been based on broad-based coalitions and interest groups.
Some New Zealand Evidence
It is not proposed to go through the impressive evidence linking smoking to morbidity and mortality, since it is well known. In summary, it is estimated that smoking one cigarette shortens the smoker’s life by 5.5 minutes.(4) However New Zealand has some evidence which is not well known internationally, and so is reported here.
The New Zealand Census may well be unique in that it has asked questions on the prevalence of smoking. Those over 15 are asked whether they were ever a regular smoker, and if they were, whether they still smoke. Because this is asked of the entire population, it is possible to look at prevalence in any sub-population.
Figure 2M shows the proportion of males who said they had been regular smokers by five-year periods of birth. It shows a steady decline through the generations (with the possibility that the decline has accelerated for the most recent cohort). However, the graph is misleading for it only reports the living. If we allow for the differential mortality for smokers we find that the proportion of regular smokers among those born in a particular period, as distinct for those alive in a later one, was much higher, and the decline sharper. The same story applies for females. (Figure 2F). According to the census the proportion of women who have been regular smokers has been rising. In fact about 50 percent of each cohort have smoked. The apparent rise is a consequence of the higher mortality of smokers. (Note that ever-smoking prevalence is higher among women than men in recent cohorts).
(The ever-smoking prevalences give little indication of current-smoking prevalences. In 1996 24.8 per cent of adult males and 22.7 per cent of women were still smoking. This gives a quit rate for all adults of just under 50 percent. For older still living adults the quit rate is over 75 percent for those over 65 years, and actual smoking prevalences are close to 10 percent.)
Knowing someone (or generation) is, or has been, a regular smoker says nothing about the levels of consumption. In New Zealand they are only available in aggregate for long time periods. Figure 3 shows the pattern of adult tobacco consumption in cigarette equivalents from 1920 to the 1990s. There is a big rise in the late 1930s and 1940s, with increasing affluence and more successful marketing of cigarettes (especially among women), plus the impact of the war, when cigarettes were cheap to the troops, and conditions conducive to smoking. (In fact consumption in the war era may be underestimated, as this only reflects domestic consumption and excludes smoking by the armed forces overseas.) Per capita consumption levels then stabilized from the 1950s to the 1980s, since when they have begun to fall and are now about half their peak and lower than at any time in the last 80 years.
Figure 4 shows the lung cancer mortality rate, which peaks for men in 1965 after a dramatic seven-fold increase in 30 years. Again there is a plateau (perhaps slightly declining over time) but it is not until 1985 that male rates begin to fall markedly. The female lung cancer rates follow a different pattern, reflecting female cohorts taking up smoking later than male ones. They peak as late as 1975 (again after a more than seven fold increase albeit from a much lower base), but it is not evident that they have yet gone into the decline stage that males have.
A comparison between Figures 3 and 4 suggests there is a two plus decade lag between the rise, plateauing or fall in tobacco consumption and the rise, plateauing or fall in the incidence of lung cancer. The implications for Japan, as we saw in Figure 1, and for other countries which took up heavy smoking in the post-war era is that the main impact of lung cancer is still to come.
This must be rather depressing for oncologists working in those countries, because measure taken now to reduce tobacco consumption will not give immediate reduction in lung cancer. Nevertheless it is worth repeating the standard advice for those considering abandoning smoking.
“After a year, mortality from heart disease drops halfway back to that of a smoker; by five years, it drops to the rate on non-smokers. A person’s risk of lung cancer is cut in half in five years; by ten years, it drops almost to the rate on non-smokers. Such gains are reaped only if smokers quit in time, before they show any signs of tobacco’s lethal affects.”(5)
Thus cardiac physicians have a considerable interest in stopping smoking.
To give an order of magnitude of the problem I have calculated the social costs of tobacco use in New Zealand in 1990, came to a 1.7 percent loss of material GDP with a 3.2 percent loss of the total value of life (covering mortality and morbidity costs). A summary of the conclusions appears in Figure 5.(6)
The Anti-Tobacco Campaign in New Zealand
Each country has to develop its own anti-tobacco campaign, reflecting its constitutional and cultural circumstances. For instance the US campaign is quite different from the New Zealand’s because the US constitutional arrangements do not give a federal mandate for health care, because of the greater practice of litigation, and because the US is a major exporter of tobacco products. Nevertheless there are some general principles and policy instruments, which can be illustrated by a stylised account of the New Zealand experience.
Tobacco arrived in New Zealand with the European at the end of the eighteenth century and was taken up with alacrity by the Maori, who still smoke more heavily and suffer greater mortality from smoking than the non-Maori. A desultory anti-tobacco campaign began in the late nineteenth century. Little was scientifically known of the health effects of tobacco. Instead the campaign was largely driven by a religious puritanism (paralleled by a more pervasive temperance (anti-alcohol) campaign), and supported by similar movements overseas. Although the following is a description of the attitude of a Methodist (protestant Christians) of the 1920s, it well captures the earlier view. tobacco. Instead the campaign was largely driven by a religious puritanism (paralleled by a more pervasive temperance (anti-alcohol) campaign), and supported by similar movements overseas. Although the following is a description of the attitude of a Methodist (protestant Christians) of the 1920s, it well captures the earlier view.
“Now I don’t smoke or drink or swear …this is not just a behaviour[al] sort of thing. This is respect for the human body and this is what we were taught [in Methodism]. The human body was a temple for us to respect.” (7)
One success was the Juvenile Smoking Offending Act of 1903, which prohibited the sale of tobacco products to under sixteen-year-olds. This was a response to the arrival of cigarettes (which a youth could more easily hide than the paraphernalia of a pipe) and concerns about delinquency. A common theme of parliamentarians was that they smoked and while it did not damage to them, it was bad for growing boys. (Women were never mentioned in the debate.)(8)
, which paralleled the more pervasive temperance campaign of these times, including from overseas. The antagonism to tobacco was more a matter of puritanism than the health effects which were not scientifically known at the time. One success was the Juvenile Smoking Offending Act of 1903, which prohibited the sale of tobacco products to juveniles. This was a response to the arrival of cigarettes (which a youth could more easily hide than the paraphernalia of a pipe) and concerns about delinquency. A common theme of parliamentarians was that they smoked and while it did not damage to them, it was bad for growing boys (Women were never mentioned in the debate).
In the first part of the century the anti-tobacco movement was a feeble offshoot of the largely religiously driven temperance movement. We might call this movement incipient rather than effective, although it did discourage some people from taking up smoking.
Smoking increased throughout the first half of the twentieth century. Male regular-smoking prevalence was then over 80 percent, and female prevalence rose from about a quarter for those born before the new century to the half which has been standard for most of this century .While male smoking typically began in teenage years, women’s prevalence probably rose in the 1930s when cigarette companies consciously targeted women, and adult women took up smoking. (Today smoking is being taken up by both sexes in teenage years, at increasingly younger ages.) Earlier it was suggested that smoking prevalence peaked for adolescent males during the Second World War, and declined for those who entered teenage their years after it. Before then, increasing prevalence was associated with increasing consumption per person. Throughout this time there was as switch from pipe tobacco to cigarettes (imports and manufacture of tobacco for oral and nasal consumption was banned in the nineteenth century).
The New Zealand story is not very different from the smoking story of other Western nations (except for timing) because of globalisation of the mass media and the application of marketing strategies by the international tobacco companies. Fashion has been important.
Per (adult) capita tobacco smoking peaked in the 1950s, at a saturation level not very different from most other Western nations, but lower than the US. Per capita consumption did not really decline until the 1970s. Nevertheless it is interesting that the plateau began before the publications by British and US epidemiologists from the 1950s, which convincingly proved there was a connection between smoking and mortality.
The anti-smoking campaign of the 1960s was reinforced by the increasing numbers of quitters, who were often vigorous objectors to smoking. There was no formal anti-tobacco organization. The big transformation was that the doctors, alerted by the growing body of evidence of the disease inducing effects of tobacco and vigorously led by a few spokesmen and women, began to give up smoking themselves, and advised their patients to do so too. Of course, not all doctors did, but the medical profession gave the anti-smoking forces an organizational base. This expert dominated movement led voluntary health oriented groups -such as the Cancer Society and the Heart and Asthma Foundations -to take up public education. Today there can be few New Zealand adults who do not know that smoking kills -even if they have only a vague idea of the totality of the evidence.
The campaign also reflected an important shift in medical policy thinking at that time. The dominant view, up to the 1970s say, was that medicine could cure all illness (or they were incurable). However, there developed a realisation that many illnesses were better treated by prevention, which was cheaper, more effective, and less invasive of privacy. (There may be no better illustration of this principle than preventing cancer and heart disease by eliminating smoking. A recent paper by the New Zealand Ministry of Health nominates smoking as a significant preventable risk factor in five of the nine top causes of death in New Zealand.(9)) Emphasis on prevention and the public health paradigm steadily involved government agencies, including the Ministry of Health, who again led by their medical experts, became advocates of public education and anti-smoking policies.
And so a minority movement dominated by experts, evolved into a public movement in which experts gave leadership but the momentum came form the public. A separate anti-smoking organization was developed. (Its name, ASH, indicates the international dimension of the movement.) Civil groups without any formal health purpose joined in, for instance banning smoking at committee meetings. (That it was possible to get majorities to do so was indicative of the growing numbers and the increasing persuasive vigour of the anti-smokers). A key step was the systematic identification of the health effects of passive smoking. These are small in comparison to the impacts on smokers, but it was now plausible to argue that smokers largely knew the health risks they were exposing themselves to. Passive smoking meant that those risks were being passed onto others, without their consent. It shifted the debate. Many anti-smokers had been irritated mentally by smoking litter and the discourtesy of smokers (for until recently they did not ask whether they might smoke in one’s presence), and physically by the smoke itself. But the irritation was exacerbated by the knowledge that passive smoking also kills, adding to the crusading zeal of the anti-tobacco lobby, and to the concerns of the population
When there is a strong enough mass movement, politicians take it up. In New Zealand’s case the key politician was Helen Clark, currently prime minister, but in the late 1980s, Minister of Health, who introduced legislative which restricted smoking in the Smoke Free Environments Act (1989), which was in part based on Canadian legislation.
It is well to note that while the political phase in the anti-smoking campaign developed late out of the mass movement, there had long been a political pro-tobacco campaign, led by the tobacco companies and also the tobacco growers and processors. (The latter were eliminated by the elimination of border protection in the 1980s.) Even though the companies remain a strong lobby in New Zealand, and have the support of up to 25 percent of the population who still smoke (albeit, in the case of many addicts, reluctantly), their campaign is in retreat.
While the ambitious smoking reduction targets the government sets up as a part of its public health campaign may not be met on time, it seems likely that there will continue to be long terms reduction in the prevalence and intensity of smoking among adults. (Juvenile smoking is a more complicated issue. For a number of reasons, including adolescence rebellion, it may be impossible to stop teenagers smoking completely. The strategy may be to ensure they dont become addicted, and give up easily on reaching the maturity of adulthood.)
The history of New Zealand smoking is summarised in figure 6. The penultimate column shows a pattern of the anti-tobacco campaign of incipient expert public political movements. It is a common one in New Zealand. However it must not be assumed that there was some broad strategic overview. Rather, opportunities were seized as they occurred. (And not always the best ones. For instance the anti-tobacco campaign never aligned itself with the anti-protection campaign to eliminate the tobacco growing and processing industry.) However each mini-campaign must be seen in the context of a growing body of knowledge about the damaging effects of smoking, and a widening awareness of this knowledge among the public. Public education comes first.
Fiscal Policy and Tobacco (10)
Undoubtedly the single most effective policy instrument to reduce smoking, other than education, is raising the price of tobacco by imposing excise duties.
Because the consumption of tobacco is insensitive to changes in price (as occurs when an excise duty is increased) it is a good substance to tax (whatever the health and equity considerations). Moreover, that the consumption activity is considered problematic by a significant and vocal proportion of the population makes higher tax rates politically feasible.
Initially the fiscal pragmatism was combined with the view that consumption of tobacco was indulgent if not downright sinful. But the Minister of Finance stated in the 1970 budget “it is clear that cigarettes and tobacco can be subjected to additional tax without harming in any way the general welfare of the community .In fact it is increasingly argued that discouraging the consumption of these commodities is likely to make a positive contribution to our general health.” By the 1977 budget the view had moved to “the adverse effects on health of smoking and drinking have been well publicised.” The notion that excises on tobacco consumption for health purposes is now an integral part of the justification for the duty .But at what level of duty?
The narrowest view is that the duty should be sufficient to cover the cost to the state of treating tobacco-induced diseases. But these do not cover all the private costs, such as the loss of life. So there is no logical necessity that revenue from excise duty on tobacco should cover just the fiscal costs of tobacco consumption. Whether through health and social cost arguments, or through modern variations of the purity argument (in modern economic parlance presenting tobacco as a “demerit good”), the anti-smoking pressure groups have lobbied vigorously for higher taxation on tobacco. They had marked success in the late 1980s and early 1990s, for the government under fiscal stress found it convenient to respond positively to the lobbyists’ demand.
In evaluating the impact of excise duty , we need to think of at least three groups of smokers with differing behaviour, although little is known about their proportions, other than anecdotally.
(1) The addicted, typically older, smoker who has already resisted a range of economic and non-economic incentives to give up smoking. For most, a hike in excise duty reduces their real income, rather than their tobacco consumption.
(2) Occasional, light, and non-addictive (adult) smokers whose consumption may be price elastic/sensitive to price increases. This group may not be a high policy priority except to discourage their joining the first group.
(3) New and potential smokers, who in New Zealand are almost entirely teenagers, since few begin smoking after the age of 18. Higher prices do affect their consumption levels. The effects of higher excise duty may discourage adolescents becoming heavy and addictive smokers (joining the first group).
A tax hike will impact on these different groups in different ways. In particular it may not be particularly effective on the first group, but may be effective on the long term smoking behaviour of the third. Nowadays, a central theme of the anti-tobacco lobby’s call for higher tobacco duties is that higher excise duties prevent adolescence addictive smoking.
As reported in the historical section, legal prohibition on juveniles from being supplied with tobacco products, or smoking in public places, were imposed at the turn of the century. Other prohibitions began to be imposed in the late 1980s. The main ones can be summarised as follows:
(1) Restrictions on commercial access to tobacco by the young (currently under 18).
(2) Prohibitions on advertising, sponsorship, (with a few exceptions, typically concerned with international events), display, and compulsory labelling including health warnings.
(3) Creation and extension of smoke free environments. (The rules have been supported by many businesses – most evidently airlines – happy to comply in their own interests while attributing the restrictions to the government.)
(4) There is a little subsidization of quit programs, although the general approach of the New Zealand government is that these are the responsibility of the individual, and so should be the funding.
For completeness it is mentioned that there are also private restrictions on smoking. For instance the Maori, having taken over responsibility for their (typically government funded) own anti-smoking campaigns, have applied smoking prohibitions to their marae (meeting areas and halls).
I will not discuss here the policy issues and instruments which currently face New Zealand, with one exception. There is an increasing need for international coordination among the Western Nations of anti-tobacco policy because of border issues. These include smuggling, duty free allowances and cross-national advertising and sponsorship. Undoubtedly the measures will impact on other countries.
Developing an Anti-Tobacco Policy in Another Country
Every country is politically and culturally different from another, so while each can learn from the experiences of others, its campaign will be unique. But the New Zealand experience suggest some general principles. The first is that when the campaign is in the expert phase led by concerned health professionals, the next likely next stage is going to be a public phase, which develops out of a program of increasing public education. Probably it will work most effectively when there are some other factors changing the public’s view, indicated by a slowing down in the increase in tobacco consumption or a plateauing. Quitting will become more common, especially among the elite or those who set public opinion.
It will be a long campaign. David Hay’s return to New Zealand in the mid 1960s is a marker for the beginning of the expert phase of the New Zealand anti-tobacco campaign. We observe that there were little observable gains in terms of aggregate tobacco consumption for the next two decades, and for reductions in male lung disease for three. (The situation for women is more problematic. But it seems likely that without the campaign, their consumption levels would have rise, and quitting have been less common. So their gains may be the plateauing rather than rising of the female lung cancer rate).
Yet if each country’s campaign is unique, it is also greatly influenced by the success and failure of campaigns of like-minded countries. New Zealand has been greatly influenced by UK and US research on the dangers of smoking, and by Norwegian and Canadian legislation to ban advertising. Australian was followed on health sponsorship and California on smoke-free legislation. In taxation New Zealand has created been a world leader. It is perhaps to be regretted that the US campaign has not got the traction of the rest of the West, because of its different circumstances, given how trend setting the US tends to be.
One would predict therefore that the anti-tobacco campaigns in those countries which took up smoking from the fifties will have parallels with the earlier Western campaigns, but also have differences, but some of those differences will be common across those countries moving into the expert phase, and beyond.
Figures Not included on website.
1. British vs Japanese Lung Cancer Mortality.
2M: Ever-smokers: Entire Cohort & Live cohort (Male)
2F: Ever-smokers: Entire Cohort & Live cohort (Female)
3: Per Capita Tobacco Consumption: 1921-1991
4: Ling Cancer Mortality Rate: 1940-1995
5: Social Cost of Tobacco Use in NZ (1990)
6: A History of the NZ Anti-Anti-Tobacco Campaign.
1. I am grateful to Drs Alan Gary and Murray Laugeson for useful comments on an earlier draft of this paper.
2. An interesting consequence is the Japanese have mainly filtered cigarettes. The sdmoke particles have thus penetrated deeper into their lungs, and so their pattern of lung disease may differ.
3. His services in the anti-tobacco campaign were a major contributor to the justification for the knighthood.
4. C.E. Bartecchi, T.D. MacKenzie & R.W. Schier (1995) “The Global Tobacco Epidemic”, Scientific American, May 1995, p 44-51.
5. Office of Smoking and Health (1990) The Benefits of Smoking Cessation, A Report of the Surgeon General, U.S. Department of Health and Human Services.
6. B.H. Easton, The Social Costs of Tobacco Use and Alcohol Misuse, Public Health Monograph, Department of Public Health, Wellington School of Medicine, 1997.
7. The quotation comes from a a radio interview of a well-known New Zealander, Dr W.B. Sutch, in 1971, recalling his adolesence in the 1920s.
8. S. Thompson (1992) Evils of ‘The Fragrant Weed’: A History of the 1903 Juvenile smoking Suppression Act, Essay in partial fulfilment of M.A. degree, University of Auckland.
9. Heart disease (1), stroke (2), chronic lung disease (3). Asthma (6), lung cancer (8=). Other risk activities were physical inactivity, obesity, and diet.
10. This section is based on B.H. Easton, “The Economic Regulation of Tobacco Consumption in New Zealand”, in I. Abedian, R. van der Merwe, N. Wilkins & P. Jha, The Economics of Tobacco Control: Towards an Optimal Policy Mix, Applied Fiscal Research Centre, University of Cape Town (1998) p.293-305.