Monday, 4 January 2016

A missing option

Nick Wilson and his usual coauthors survey the potential regulatory options for e-cigarettes in a viewpoint piece in the NZMJ. But I think they're missing an obvious option.
While e-cigarette usage has grown rapidly in New Zealand and around the world, the scientific evidence base regarding the net benefits and risks of these types of products at the population level remains uncertain. The health-based policy experience is also minimal. Here, we analyse plausible future regulatory options for e-cigarettes that the New Zealand Government could explore, and that further research could help clarify. These options include: (1) a full free market (an option we doubt is desirable for multiple reasons); (2) controlled increased access through: (a) pharmacy only, (b) pharmacy only plus sales by prescription/ to licensed vapers; (c) additional controls through non-profit supply/distribution (eg, public hospital pharmacies); (3) increased restrictions compared with current (eg, adopting a complete ban on self-imports and use). In addition, we consider mechanisms to improve product quality and safety, and argue that policy makers should take great care when regulating e-cigarettes, given the scientific uncertainty and the role of commercial vested interests. 
Ok, what's the missing option? The kind of regulated sales currently allowed for alcohol and tobacco where vendors are prohibited from selling to minors. We'll come back to this.

Wilson et al note that free and unregulated sales largely exist in the US and parts of Europe, but rule that out for New Zealand. Why?
It seems fundamentally problematic for society to allow a highly addictive drug (such as nicotine) to be sold in unregulated environments without health professional advice and support for quitting.
But surely that has to depend on whether there are substantial unforeseeable adverse consequences from that addiction! I experience minor withdrawal symptoms when I can't have a coffee; I enjoy coffee; I would hate to have to have doctor's permission for each cup. In a free society, these choices have to be left to the individual. Would they have a doctor on-site at every bar and off-licence to provide health professional advice to anyone buying a drink?

The main issue with addictive potentially harmful substances is that youths might lock themselves into long term consumption paths that they might regret as adults. And so the government restricts sales of alcohol and tobacco to children. What's wrong with that approach for e-cigarettes? Wilson et al say that just doesn't work - at least in the case of tobacco.
Existing tobacco outlets (especially dairies) appear to chronically break the law around tobacco sales (eg, 64% breaching regulations in one survey and extensive evidence of sales to underage youth25-28).
Ok, let's check their cites here.

25 is Quedley et al, 2008. 26 is Marsh et al 2012, which investigates changes 2000-2008. 27 is Gautam et al 2014, which looks at data 2007-2009.

Why do these years matter? In 2011, the legislation tightened up around sales to minors. Section 30 of the Act prohibits sales of tobacco products to people under 18; the 2011 Amendments increase the fines. Individuals can be fined up to $5000; body corporates, up to $10,000. So stuff from prior to 2011 might not apply all that well.

What about reference 28? That's Grendall, Hoek et al 2014. They looked at seven survey waves of ASH's survey of Year 10 students: 2006-2012. So it includes a bit of post-2011 data. What do they find?
Results Smoking prevalence declined significantly (8.1%) over the period examined (linear tend coefficient: −0.74; 95% CI −1.03 to −0.45, significant p<0.01). Friends showed a significant decline in relative importance as a supply source while caregivers and other sources showed a significant increase over the period examined.
Conclusions The findings show that social supply, particularly via friends, caregivers and others, such as older siblings, is a key tobacco source for adolescents; commercial supply is much less important. The findings raise questions about the additional measures needed to reduce smoking among youth. Endgame policies that make tobacco more difficult to obtain and less appealing and convenient to gift merit further investigation. [emphasis added]
So the only post-2011 data they cite doesn't really support that commercial supply is a big issue. And it doesn't look to have been a major issue before 2011 - at least among Year 10 students surveyed.

Before 2011, just over 10% of Year 10 kids (aged 14 - 15) who smoke got their smokes from shops. Since then, it's declined slightly to 10%. Friends are the main source of supply: those could be 17 year olds who bought illegally at shops, or 18 year olds who bought them legally. Maybe some of the drop in supply from friends was due to increased tobacco cost with the excise hikes; maybe it's just the ongoing decline in smoking rates that mean it's harder to bum a smoke off somebody. But if some of those friends were 17 year olds who'd previously purchased illegally, well, the substantial drop in 2011 would be consistent with retailers being more wary about selling to minors.

I suppose it's a judgement call as to whether 10% of youths getting smokes from shops constitutes "extensive evidence of sales to underage youth".

Sure, you can find retailers selling to youths in stings, but simply applying the existing fines a bit more thoroughly would seem a better answer than concluding we can't really restrict sales to minors - especially where it doesn't particularly look like retailers are the direct source of youth supply.

The NBR asked me for comment on a new NZ Taxpayers' Union report on tobacco taxation, which kindly cites me heavily. I told them:
"It is absurd that the government makes it difficult for smokers to access nicotine cartridges for e-cigarettes," he says.

"Smokers wanting to switch to that much safer alternative currently need to import their cartridges because retailers here are forbidden from selling them.

"That's fine for Wellington hipster vapers who can find the foreign suppliers, but not so fine for the lower decile groups where harms are concentrated. Why are we even talking about increasing the excise rate on cigarettes when allowing and promoting switching to vaping would do far more to reduce harm?"

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