‘Total ban’: could this be the last generation of smokers?

Beyond the usual memorable factors - fears about the millennium bug, the dawn of the 21st century - 1 January 2000 is a significant date in Brookline, Massachusetts. In the town, on the outskirts of Boston, vendors are legally banned from selling tobacco products and e-cigarettes to anyone born after Y2K.

The legislation came into effect last September, after a vote in November 2020, making Brookline the first US town to implement such a law, in the hopes of gradually phasing out smoking for younger generations.

It isn't clear how effective the policy in Brookline will be, given the town's proximity to other jurisdictions where sales are legal. But similar proposals - often termed policies for "tobacco-free generations" (TFG) - are now being considered at the national level by several countries.

New Zealand is set to introduce a law this year which would prevent anyone aged 14 and younger - when the legislation takes effect in 2023 - from ever legally buying smoking products. Unlike Brookline, New Zealand's policy will not include a ban on e-cigarette sales. Lawmakers in Denmark are considering a similar proposal for anyone born after 2010, and in recent months both the Malaysian and Singaporean health ministries have flagged their intention of following New Zealand's lead in aiming for a tobacco endgame. Should Australia consider similar legislation?

In Australia, tobacco smoking is the leading cause of premature death and disability. It kills more people in this country each year than alcohol, car accidents, murders, suicides or - in the past two years - Covid, points out Jon Berrick, an emeritus professor at Singapore's Yale-NUS College, who now lives in Sydney.

A mathematician by training, Berrick developed a personal interest in tobacco policies and was one of a group of researchers who floated the TFG idea in a 2010 paper. It suggested 2000 as a threshold birth year for a "long-term phasing-in of a total ban".

Smoking rates have declined steadily in Australia since the 1990s, to 11.6% of adults in 2019. Between 2001 and 2019, the proportion of daily smokers aged 18 to 39 has halved, though figures have not improved in those in their 50s and 60s.

Proponents of TFG laws believe it is a more palatable option than an outright ban on all smoking products.

"You can't just ban it overnight. What happens to the people who are dependent on it?" Berrick says. Sales restrictions based on birth date would instead concentrate efforts on preventing adolescents from taking up smoking in the first place, he says.

To date, there has been one attempt to implement TFG legislation in Australia - an unsuccessful private members bill in Tasmania, introduced in 2014 by the independent MP Ivan Dean.

The state would be well placed for implementing a TFG proposal, says Dr Kathryn Barnsley, an adjunct researcher at the University of Tasmania and convenor of SmokeFree Tasmania. "We've got a very good licensing system and highly efficient enforcement of sales to minors in Tasmania, which some of the other states don't have."

The sale of tobacco products, as well as enforcement of regulations, is under the purview of state governments, "with the exception of some commonwealth legislation relating to advertising and packaging", Barnsley says.

There are, however, hints at age restrictions in the latest consultation draft of the 2022-2030 national tobacco strategy, which proposes to "consider the feasibility of raising the minimum age of purchase of tobacco products and monitor international developments on this matter".

TFG proposals are not without critics. Dr Brendan Gogarty, of the University of Tasmania, wrote in The Conversation in 2016 that while smoking "represents a significant social danger", the legislative response to social risks "must be evidence-based and considerate of constitutional limits and civil rights".

"Targeting laws at people who cannot hold lawmakers to account at the polls is undemocratic. It is also unfair to have one generation telling the other to 'do as I say, not as I do'," Gogarty wrote.

He also criticised the effectiveness of tobacco prohibition: "Laws that rely on prohibition to reduce the prevalence and harm from drugs generally fail to achieve their aims. That was true of historic alcohol prohibition laws. It remains true of the continued legal prohibition on narcotics."

But Berrick points to two historical precedents for generational phase-out, in regulations that successfully curbed opium smoking in Taiwan, then known as Formosa, in 1900 and Sri Lanka - a British colony at the time - in 1911.

"You have to have demand to create a black market," Barnsley says. "Tobacco would remain awash in Australia or Tasmania or any other state if you brought in the tobacco-free generation proposal, because it would still be sold legitimately in outlets."

Marita Hefler, an associate professor at the Menzies School of Health Research in Darwin, is also dismissive of prohibition criticisms. "It's a lazy argument to say that 'prohibition never works' or to use the US experiment from the 1920s or even the 'war on drugs' as evidence," she says.

"After 30-plus years of policies to reduce smoking, the Australian public overwhelmingly have negative attitudes towards cigarettes and the tobacco industry.

"A majority of smokers want to quit and wish they'd never started. Most smokers don't want the young people in their lives to ever smoke."

One downside of the TFG proposal is that "this measure on its own won't achieve Australia's goal of less than 5% smoking prevalence by 2030, because it is a very slowly implemented phase-out," says Coral Gartner, an associate professor at the University of Queensland and an international expert in tobacco control policy.

"In New Zealand, it is a policy that is being brought in with a range of other policies that are likely to have a larger and faster impact on smoking prevalence, such as a very low nicotine standard for cigarettes," she says.

Gartner and Hefler are among public health experts who have argued for stricter regulation of tobacco sales in Australia, calling for a ban on cigarettes from being sold in general retail outlets.

An alternative could be designing a "pharmaceutical-like" regulatory framework, she suggests, where the products are supplied in pharmacies and "a health professional can provide advice on risks and benefits".

Hefler says any TFG proposal would need to "avoid creating a new epidemic of e-cigarette use among young people and non-smokers" - as is a potential risk in New Zealand. "But cigarettes need even tighter regulation than e-cigarettes and are overdue to be phased out," she says.

More than a decade after he and his colleagues proposed the TFG idea, Berrick seems pleased that legislators around the world are now seriously considering it as an endgame approach to tobacco. "I joke that peer influence is just as important among health ministers as it is among teenagers," he says.