The policy termites slowly eating out the foundations of smoking

Like a mound of termites, tobacco control policies are eating away at smoking in ways we’re not always conscious of. from www.shutterstock.com

Simon Chapman, University of Sydney

Across 40 years of working in tobacco control, there have been countless times when I’ve been asked “so, has [insert here] policy or [insert here] campaign worked?”.

The question has its roots in clinical interventions where we see what happens when you take an analgesic for pain, get an injection before having a tooth pulled, or apply a fungicide on athlete’s foot. These things work.

So it’s natural we should ask the same about a piece of legislation or a multi-million dollar TV campaign about smoking. Do these things make a difference?

In 1993 I wrote an essay on this issue in the British Medical Journal, Unravelling gossamer with boxing gloves: problems in explaining the decline in smoking.

In the wake of Philip Morris being ordered to pay the Australian government about A$50million in legal costs over the company’s failed attempt to thwart plain packaging, I was asked the question again this week: “Has plain packaging worked?”

So here’s an update on the direct and subtly synergistic ways tobacco control has seen Australia achieve record lows in both adult and teenage smoking.

From a trickle to a deluge

Since the bad news on smoking and health began to trickle in from 1950, then deluged us, hundreds of millions of smokers have stopped smoking around the world, particularly in nations where governments have introduced population-focussed laws and regulations. These include measures like laws, taxes and mass campaigns that reach huge proportions of the population as opposed to dinky little interventions very few people ever see or are exposed to.

When a smoker decides to quit, they will have usually tried before – many with about the same conviction as attempts to exercise more or lose weight. But when they finally succeed, ex-smokers will often nominate a reason “why” they quit.

There is broad daylight between the first reason ex-smokers give about why they quit and all other reasons they nominate. Health concerns are the overwhelming reason for quitting (91.7%), followed by cost (way back at 58.7%); 90% of smokers regret they ever started.

The straw the broke the camel’s back

People also often nominate a recent “straw that broke the camel’s back” as the precipitating reason for the final decision to quit and resolve to see it through.

This can be a symptom they have experienced, an incident like the sudden death of a smoking friend, a particularly poignant campaign advertisement they can’t get out of their head (this classic has few peers), the heartfelt pleading by a child or partner, the sudden realisation very few of their colleagues or friends smoke or the price of cigarettes going through a psychological barrier, like A$40 a pack.

These triggers are known as proximal factors that stimulate quitting: factors easily identified, nominated by smokers aware of their influence, and sometimes easy to quantify with proxy measures like immediate boosts in calls to quitlines.

Background factors that eat away at smoking

But there are also vital distal or background factors that work like hidden termites in a building. These slowly and subconsciously eat away the foundations of smokers’ feelings of being invincible to disease, their apathy and act to denormalise pro-smoking environments. The effect is that smokers get fewer reminders about smoking and a growing awareness smoking is not something the great majority of people do anymore.

Examples of these distal factors are advertising bans, graphic warnings on packs, plain packaging, smoke-free public spaces and tobacco taxation.

Very few smokers tell you they quit smoking because tobacco advertising was banned. The impact of advertising bans instead works in slow-burn fashion, as it has done in Australia since 1993 when the last forms of advertising ended.

With plain packs, some smokers experienced an increased urgency to quit after exposure to the purposefully unappealing plain packs with their goullish (but deadly accurate) large graphic health warnings. But the primary goal was to have whole generations grow up never having being beguiled by the designer edginess of pack livery and noting plain packaging of tobacco products was exceptional among all other consumer goods.

Tobacco is the only product where legislation mandates plain packaging: 17 nations have either implemented, legislated it or announced they will. Tobacco is also the only product that has to be stored out of sight in retail outlets.

All these factors do not act in isolation, but like a constant and unstoppable termite colony, working in synergy to erode the appeal of smoking.

A day in the life of an ex-smoker

In my 1993 BMJ essay, I described a day in the life of a smoker who quit. The smoker woke to news on the radio of yet more bad research news about smoking; lived with disapproving family members who often urged him to quit because they had been educated about the risks; winced every time at the price he had to pay for a pack; was acutely aware of all the places he couldn’t smoke and why those laws had been introduced; was self-conscious about the stench of stale tobacco he carried about; and couldn’t shake some of the powerful anti-smoking advertising that intruded his TV viewing.

A smoker might well nominate just one of these influences when a researcher calls, but all play a part in a comprehensive approach to reducing the world’s leading cause of death, if you exclude poverty.

Humans are not like lab rats who can be artificially kept in strictly controlled environments and exposed to single or fixed combinations of policy variables while isolated from all others so researchers can measure the exact impact of any one factor.

People whose questions are based on that premise need to be gently reminded of that. Male lung cancer incidence rates today were last seen in the early 1960s and women’s seem likely to never reach even half the peak seen at the height of the male epidemic. We need to stay the course and make smoking history.

Simon Chapman, Emeritus Professor in Public Health, University of Sydney

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.

Cheaper cigarettes, roll-your-own tobacco slows smoking’s downward spiral

While smoking in young Australians is declining, roll-your-own cigarettes are becoming more popular. from www.shutterstock.com

Simon Chapman, University of Sydney

Yesterday morning, Australia’s tobacco industry woke to the latest chapter in the book documenting its inexorable decline.

The Australian Institute of Health and Welfare released data from its 2016 National Drug Strategy Household Survey, which it has conducted every three years since 1985.

While it was always going to be hard to show even further decline in teenage smoking from what was an already very low level, it’s happened again.

The proportion of teenagers (aged 12-17) who have never smoked more than 100 cigarettes significantly increased between 2013 and 2016, from 95% to 98%. Smoking more than 100 cigarettes in a lifetime has long been used in Australia as a benchmark question to sort curious, experimental smokers from more committed and addicted smokers.

Younger people also continued to delay when they first smoked their first full cigarette. This increased in the 14 to 24-year-olds from 14.2 years in 1995 to 16.3 in 2016 (a statistically significant increase from 15.9 years in 2013).

Catch ‘em young

The tobacco industry knows it needs to attract and addict new consumers to replace those who stop smoking through quitting and death. As a 1981 report sent to the then vice-president of research and development at Philip Morris put it:

Younger adult smokers are the only source of replacement smokers … If younger adults turn away from smoking, the industry must decline, just as a population which does not give birth will eventually dwindle.

Australia’s plain packaging legislation, implemented in December 2012, was aimed at reducing teenage Australians taking up smoking. As the health minister who introduced it, Nicola Roxon emphasised in April 2010 when announcing the policy:

We’re targeting people who have not yet started, and that’s the key to this plain packaging announcement – to make sure we make it less attractive for people to experiment with tobacco in the first place.

As Australian young people have turned away from smoking, the tobacco industry is left scrambling for new ways to addict young customers to nicotine.

Total smoking levels remain level

The proportion of people of all ages who smoke was also not good news for the tobacco industry.

The percentage of people aged 14 and over who smoke daily is down from 12.8% in 2013 to 12.2% in 2016. While any decline is welcome, this was less than it should have been, and the first time in two decades that a statistically significant fall was not recorded.

There are several factors likely to be responsible for the previously brake-less downward slide in smoking.

Long-time campaigners Mike Daube and Todd Harper have set out nine strategies the Australian tobacco industry has used so it can keep earning from the deaths of two in three Australian smokers likely to die from using their products.

Two critical factors here are price discounting and the dramatic rise of roll-your-own tobacco.

How price discounting works

Plain packaging means brand differentiation is gone as all packs look the same, except for the written brand name. So, the ability of branding to convince gullible smokers that premium (expensive) brands are somehow “better” and worth spending more on than cheaper, budget brands goes out the window.

After plain packaging was introduced, there was an industry-wide decision to cut prices to compete with lower priced brands for market share. There were large tobacco tax rises in the run-up to plain packs being introduced (25% in 2010) and a further 12.5% each year from 2013 to 2016.

Again, the tobacco companies cut their margins by desperately trying to keep some brands below A$20 a pack, a price known to trigger quitting.

These practices may see renewed interest in floor pricing of tobacco products, when a price is set below which a product cannot be sold.

Rise in roll-your-own tobacco

Tobacco companies have also aggressively pushed cheaper roll-your-own tobacco by introducing loose tobacco with cigarette brand names. The tax in roll-your-own tobacco will rise from September 2017, which may see a further round of price discounting to try and stop people quitting.

The use of roll-your-own cigarettes has gone from 26% of smokers in 2007, to 33% in 2013 and to 36% in 2016. Lower price is one factor driving this, but so too are the quite erroneous beliefs that roll-your-own tobacco somehow contains fewer additives and is less harmful, an issue I will explore in my next column.

The increase in roll-your-own cigarettes since 2007 has been largest among smokers aged under 40 (increase of 82% for young adults and 70% for smokers in their 30s between 2007 and 2016). Between 2013 and 2016 roll-your-own use in smokers in their 30s jumped from 29% to 37%.

National campaign wheels fallen off

Sustained and adequately funded mass media campaigns are a vital component of strategies health authorities recommended to change health behaviours, like smoking.

And with smoking, one of the most obvious pieces of evidence comes from ex-smokers about why they stopped smoking. There are light-years between the answer that has always been given (concern about health) and everything else (cost, social unacceptability, pregnancy etc).

In this study of smokers in 20 US communities, 91.6% of ex-smokers nominated “concern for your own current or future health” as why they quit compared with 46.5% who nominated “pressure from family, friends or co-workers”.

Without large scale, on-going campaigns that reach large proportions of the population with unforgettable, motivating information about why smoking is so harmful, the core driver of quitting and not starting smoking may wane.

Regrettably, Australia’s world famous national tobacco campaign that started in 1997 and has been used by many other countries, has been mothballed since 2013 when the Coalition government took office.

Smokers still get sporadic small bursts of quit smoking ads on television in some states from state health departments. But they are not getting a fraction of the highly motivating exposures that were a big part of our earlier rapid declines. This absence is almost certainly a major factor explaining the slow down in people quitting smoking.

E-cigarettes

The latest stats show that while around 31% of smokers (ie 3.8% of the 14+ population) had ever tried e-cigarettes, 20% seemed to have done so out of curiosity (once or twice) with only 4.4% currently using them (the remaining 6.8% no longer use them). Just 1.5% of smokers were using e-cigarettes daily (0.8% of ex-smokers and 0.2% of never smokers).

There’s no evidence from these very small numbers that e-cigarette use is contributing to falling smoking in Australia.

Many are concerned that the tobacco industry (which has bought into vapourisers big time) has a business plan to have smokers vape and smoke, not vape instead of smoking. If that plays out, increases in vaping may in fact act to further slow people from quitting smoking. The next few years will provide important information on this important issue.

Simon Chapman, Emeritus Professor in Public Health, University of Sydney

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.

On the pleasure of smoking

Simon Chapman, University of Sydney

Repeatedly, studies have found a large majority of smokers regret ever starting to smoke: 85% in this study, 90% in this four nation study. Each year, some 40% of smokers make an attempt to stop, with most relapsing within weeks.

Many fork out considerable money in pharmaceuticals along the way in the attempt to shake their smoking. Snake-oil, evidence-free quick-cure merchants advertising on telegraph poles for “laser therapy quitting” happily make up to A$500 from the more gullible.

With 12.8% of Australians aged 14 and over smoking daily, and 90% of these regretting they ever started, today just 1.28% are contented smokers. Recent evidence shows 55% of young smokers now approve of plain packaging with their ghoulish, unavoidable picture warnings. Can there be any product that enjoys less consumer satisfaction and customer loyalty?

One of the most common taunts pro-smokers hurl at tobacco control advocates with great relish is the claim they are enemies of pleasure: they just can’t stand the thought or sight of people taking pleasure from smoking. Perhaps they are right. Airport smoking rooms strike me as about the most fun and pleasure you could get. The queues of non-smokers you see waiting to get in just to experience it all pretty much clinch that argument.

The picture being painted here is of elegant smokers, hand gesturing and exhaling as in Richard Klein’s Cigarettes are sublime constantly pleasuring themselves in a way denied to non-smokers who have not woken up to the joys of nicotine.

But what is it that nicotine addicts like about pulling the chemical deep into their lungs some 90,000 times a year?

In 1994, the New York Times published the ratings of two of the USA’s most renowned addiction specialists, Neil Benowitz and Jack Henningfield, on the relative addictiveness of nicotine, caffeine, heroin, cocaine, alcohol and marijuana (cannabis). They rated each of these on a scale of one (most serious) to six (least serious).

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Both rated nicotine higher in dependence than all the other drugs. By “dependence” they meant how difficult it is for the user to quit, the relapse rate, and the percentage of people who eventually become dependent.

Nicotine withdrawal also rated high (third behind the often discussed agonies of alcohol and heroin withdrawal). Both experts rated nicotine fourth behind cocaine, heroin and alcohol when it came to reinforcement (essentially, the pleasure given by the drug). But both rated nicotine last on intoxication, behind even caffeine.

Taking all this together, a picture emerges of nicotine dependent people regretful they started smoking, living in full knowledge of their high dependency, experiencing often unpleasant withdrawal symptoms when they have not been able to smoke for a while, and being relieved of this unpleasantness quickly when lighting up another cigarette.

Nicotine withdrawal symptoms include headache, nausea, constipation or diarrhoea, fatigue, drowsiness and insomnia, irritability, difficulty concentrating, anxiety, depressed mood, increased hunger and caloric intake and of course, constant tobacco cravings.

Smokers know from the earliest days of their addiction these feelings can disappear within a few seconds as the nicotine is rapidly transported from their lungs to their brains where dopamine is released and experienced as pleasurable.

Smokers often insist the pleasure from this release can somehow be experienced independently of the pleasures of the nicotine withdrawal symptoms rapidly dissipating.

So what is the “pleasure” being experienced here? When you have a toothache and this is relieved by a strong analgesic, your mood can quickly elevate as the codeine begins to work.

The argument that smoking and inhaling nicotine is “pleasurable” is a bit like saying being beaten up every day is something you want to continue with, because hey, it feels so good when the beating stops for a while.

Holiday periods like the upcoming Christmas break are time-honoured opportunities for smokers to make quit attempts. I used to smoke (in late school and to my mid 20s). I thought smoking was a great way to make a statement about myself that would impress those I cared to impress and irritate those I cared to irritate. But I always thought it tasted disgusting, was a stupid thing to continue and threatened to limit my early career opportunities.

I recall just drifting out of smoking, a pathway common to many ex-smokers. And like many smokers, I recall it being anything but difficult or torturous. This is one of the best kept secrets in tobacco control. While there are many smokers who struggle to quit and fail many times, there are many more who found the experience easier than they expected, sometimes far easier.

There are many more ex-smokers in Australia than smokers. The common narratives of quitting smoking ushering in the pleasures of tasting food and drink better, feeling physically better and of course the pleasure of having more disposable income can be compared with the supposed pleasures of smoking. Good luck if you are planning to quit. It’s the single most important thing you can do to improve your health.

Simon Chapman, Emeritus Professor in Public Health, University of Sydney

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.

If smoking doesn’t kill, Mike Pence, neither does the plague

Simon Chapman, University of Sydney

US Vice President elect Mike Pence (who has been the recipient of funding from Big Tobacco) once famously wrote:

Time for a quick reality check. Despite the hysteria from the political class and the media, smoking doesn’t kill. In fact two out of every three smokers does [sic] not die from smoking-related illness and nine out of ten smokers do not contract lung cancer.

Pence is referring here to what epidemiologists call the “case fatality rate”: the proportion of deaths from a smoking-related illness to the number of new smoking-related illnesses diagnosed. According to him, the case fatality rate for long term smoking was “only” one in three, meaning only one in three long-term smokers die from a smoking-related illness (such as cardiovascular and respiratory diseases, and smoking related cancers), which somehow meant to him smoking doesn’t kill.

By Pence’s reasoning there are many other diseases that “do not kill”. This extensive list of various diseases’ case fatality rates shows many well known highly fatal diseases with case fatality rates lower than 33%.

These include oropharyngeal anthrax (anthrax that manifests in the mouth and throat), yellow fever, treated bubonic plague, diphtheria, meningococcal disease, legionnaires’ disease, dengue fever and untreated typhoid. The 1918 Spanish ‘flu which was estimated to have killed 50-100 million people globally, had a paltry case fatality rate of around 2.5%.

Pence was also wrong about the rate at which smoking kills. A landmark study of over 34,000 British male doctors (females were excluded when the study commenced in 1951 because there were insufficient numbers of women doctors at the time) has long been the benchmark for the risks of long term smoking.

When the study reported its 50 year follow-up of the cohort, it found “the eventual risks vary from about one half to about two thirds” of all doctors who had smoked had died from a tobacco-related disease.

An Australian study of 204,953 people also confirmed the two in three death rate from smoking.

Today smoking kills some six million people a year globally, and will kill one billion people this century if present trends continue.

The US is the only significant country to have not ratified the World Health Organisation’s Framework Convention on Tobacco Control (the US tends to not sign global treaties). Under a Trump administration, will we see the end of regulation and strict marketing protocols? Will the US be the only nation to ever see a rise in smoking rates after decades of continual falls?

Simon Chapman, Emeritus Professor in Public Health, University of Sydney

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.

How the tobacco industry is gaming Australian health regulations

Steven Greenland, Swinburne University of Technology

Australia’s tough tobacco regulations are acting as a catalyst for the industry to develop sophisticated marketing practices. These companies are gaming the system by anticipating regulatory impact and then using unregulated marketing elements to overcome it.

Australia has been a guiding light for countries looking to improve public health through the effective regulation of tobacco, which remains the world’s biggest cause of preventable illness and death, and still kills around 15,000 Australians annually.

December 2012 saw the implementation of Australia’s innovative plain packaging legislation, this was followed by four 12.5% annual tobacco tax excise increases. As a result the number of Australian smokers has fallen to a record low.

However the tobacco industry has used several strategies, including price reduction, brand differentiation and promoting the idea of healthier cigarettes, to undermine Australia’s new regulatory environment.

Plain packaging was introduced in 2012 to much fanfare, but tobacco companies are making serious efforts to alleviate the effects of plain packaging on their bottom line.
Lukas Coch/AAP

Pricing for packets

To offset price hikes manufacturers have expanded lower priced product ranges, with new ultra low priced brands. One example of this is the British American Tobacco Australia’s (BATA) Just Smokes, which sells for around 70% of the premium brand prices. BATA has also shifted Rothmans, previously a premium brand, into the economy segment by cutting its price by more than 30%.

Another pricing initiative is twin pack promotion. Most consumers recognise that progressively larger packs offer progressively lower unit prices – a lower cost per single item or single pack.

This used to be true for tobacco, with the largest cartons (usually with 200 cigarettes) offering best value. However, since 2012 discounted twin packs represent best value.

A supermarket twin pack, per cigarette price, is up to 10% cheaper than single packs – effectively discouraging single pack purchases. Australia’s leading brand Winfield twin pack, per cigarette price, is equal to or below that of larger cartons.

Regulatory price increases are financial deterrents to smoking. The low price branding and discounting strategies in Australia are clear attempts to get around these, and reduce smokers’ financial motivation to quit or cut down.

Heavily discounted twin packs also teach smokers, through financial reward and penalty, to buy twin rather than single packs. This is of particular concern since research shows that larger purchases trigger higher consumption.

In 2014 the industry claimed tobacco consumption had actually increased after plain packaging. While this was disproved, it suggests big tobacco anticipated increased consumption as smokers switched to twin pack purchase behaviour.

New tobacco products and promotions

Plain packaging was expected to restrict tobacco brands. However, after 2012 manufacturers introduced numerous new products, and brand ranges actually expanded.

For example, Australia’s leading brand Winfield supported more than 20 brand variants in 2015-2016 compared to just 12 in 2012-2013. Brand differentiation is a proven marketing approach for generating greater sales, with each variant targeting a specific consumer market segment.

Since plain packaging was introduced, tobacco companies have varied the names of brands as well. Names have evolved to include the information previously covered by packaging, such as colour and new product features. For example, Dunhill Infinite is now Dunhill Infinite White + Taste Flow Filter.

Today around 80% of Australia’s leading brands’ variant names include a colour, compared to less than half before plain packaging. Tobacco companies are also using colours to mislead consumers that certain product ranges are “healthier” options.

A universal colour code has been promoted by the industry in which smokers interpret lighter colours (white, silver, gold, yellow and blue) as being less harmful, and darker colours (red and black) as more harmful. Before plain packaging colour hues were a pack design component, now the myth of healthier tobacco options is perpetuated by colour names. This is disturbing from a public health perspective as it represents industry efforts to lessen smokers’ health motivations for quitting.

The effects of clever marketing

Australia’s tobacco regulations have significantly reduced smoking. However, their impact would be greater without unscrupulous industry initiatives to overcome and thwart them.

Industry response to plain packaging and excise increases have not been simple marketing efforts to increase sales, but illustrate cynical attempts to reduce financial and health motivations for quitting, and to encourage smokers to smoke more. Australian regulators, and those in other countries, should therefore consider further regulation.

Research suggests that future effective controls might include:

• Introducing a standard fixed per stick price for all cigarettes – preventing differentiation by price and cheaper brand options
• Prohibiting price variation by pack size – preventing volume discounting or twin pack promotion that encourage smokers to make larger purchases and smoke more
• Restricting pack size to a maximum of 10 or 20 cigarettes to limit increased consumption associated with larger pack sizes
• Banning colour variant names – removing colour-health connotations
• Restricting brand variant ranges, for example to one variant or representation per brand, to limit the way tobacco companies use differentiation to increase sales.

The tobacco industry is committed to gaming regulations, like plain packaging and tax excise increases, and developing approaches to undermine their impact. However, the Australian government is equally committed to reducing the national adult daily smoking rate to 10% by 2018. The additional tobacco controls outlined above should help the government achieve this.

Steven Greenland, Associate professor, Swinburne University of Technology

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.

How might Big Tobacco react to a rise in cigarette excise?

George Rennie, University of Melbourne

There now appears to be bipartisan recognition in Australia of the political stench of cigarettes. Labor governments have taken a dim view of smoking for at least a decade, but now even the Liberal Party is joining the attack.

As the campaign donations from the tobacco industry dry up, the Turnbull government has set its sights on a product that, thanks to its unfortunate tendency to kill off its natural constituency, makes for an obvious target. The government is expected to announce a rise in tobacco excise in the coming federal budget.

The current taxation debate is just a small part of a much wider effort to curb smoking rates. And with every successful legislative change in Australia, other nations are increasingly emboldened to take on an industry once considered too politically powerful and dangerous.

Australia’s plain-packaging laws are already viewed as a model for Ireland, the UK and France. Its taxes – among the highest in the world – have routinely been shown to cut smoking rates to historic lows. Its citizens now overwhelmingly accept bans on passive smoking.

Still, Big Tobacco will never give up its fight against regulation and taxes. It knows that for every day it delays change, it saves millions in profits. As such, it relies on tactics of deceit, delay and frustration, which it has developed and refined over half a century.

But it also knows that it can’t make its argument directly. Instead, it relies on rhetorically gifted proxies. To that end, Big Tobacco has collaborated with a global web of friendly lobby groups, researchers and free-market think-tanks, such as the Institute of Public Affairs (IPA). Each proxy is expected to push an agenda, such as suggesting that research on tobacco smoke is “junk science” and critics of tobacco are “biased”.

Once the research has been completed, there are always media outlets willing to dutifully repeat the industry’s claims, which are used to build a narrative of the “nanny” state repeatedly kicking the mature and informed smoker.

Capitalism and freedom – for smokers

In the West, the freedom-of-choice argument has been at the heart of most of Big Tobacco’s campaigns since the 1970s. It’s a powerful idea, but it deliberately ignores the issue of child and passive smoking.

As such, Big Tobacco primarily relies on the argument that the state is trampling on personal liberty. When plain-packaging laws were being debated in Australia in 2010 – the first such laws in the world – the industry and its allies leapt into action.

The resultant advertising campaign was designed to portray the government and anti-smoking campaigners as part of a “nanny state” that was determined to tell adults how to live their lives.

An anti-plain-packaging advertisement.

(Stuck in) Nineteen Eighty-Four

The liberty argument may be a legitimate point of debate. But Big Tobacco also contended that plain-packaging laws would fail to deter people from smoking.

The IPA pointed out the tremendous monetary value of packaging, and Australia’s vulnerability to legal challenges that would cost billions of taxpayer dollars.

But, later, a senior IPA member released a study that showed spending on tobacco products had – controlling for other factors – increased following the plain-packaging laws’ passage.

Writers in the Murdoch press reported both stories, unaware of their contradictory nature.

Media Watch on how the plain-packaging studies were reported.

(Big Tobacco’s) crime and punishment

Another line of attack suggests that high taxes on cigarettes cause crime.

In 2015, the tobacco industry commissioned KPMG to study the effects of cigarette taxes on smuggling and black market sales. Unsurprisingly, the report said exactly what the tobacco industry wanted it to – going so far as to suggest that one in seven cigarettes smoked in Australia were smuggled.

As with all industry-funded “research”, government critics were keen to regurgitate the findings.

This is a distraction tactic. It is true that very high taxes, or a prohibition, will create a black market. It is also beside the point of plain packaging – which is to reduce smoking, while allowing for some free choice, provided it is informed and adult. Such laws have proved successful to that end.

The tobacco industry, insisting that we look anywhere but at them, wants to repaint a health issue as a law-enforcement one.

However, the tobacco industry is deeply hypocritical on smuggling. It systematically floods key foreign markets with its product, in turn facilitating smuggling in Western markets. The tactic allows it to claim plain-packaging laws and taxes cause the same crime it creates.

The heart of darkness

Big Tobacco fights in this way because of what it stands to lose.

So, the industry of death continues to exact its toll. It knew that people died from smoking and passive inhalation decades before it conceded the point. It knew of children taking up smoking – it even helped them do so. It complains of smuggling while being the biggest source of the problem.

Big Tobacco does these things because it is afraid. Imagine the profits lost should other countries adopt similar messages. Tens of billions every year are at stake.

In the tobacco wars, the strategic importance of Australia is critical. Big Tobacco will go to extraordinary lengths to ensure moves to quell smoking fail.

George Rennie, PhD Candidate, University of Melbourne

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.

 

Ten myths about smoking that will not die

Simon Chapman, University of Sydney

Across forty years I’ve come to recognise many factoid-driven myths about smoking that just won’t die. If I asked for a dollar each time I had to refute these statements, I’d have accumulated a small fortune.

Their persistence owes much to their being a vehicle for those who utter them to express unvoiced but clear sub-texts that reflect deeply held beliefs about women, the disadvantaged, mental illness, government health campaigns and the “natural”.

Let’s drive a stake through the heart of ten of the most common myths.

1. Women and girls smoke more than men and boys

Women have never smoked more than men. Occasionally, a survey will show one age band where it’s the other way around, but from the earliest mass uptake of smoking in the first decades of last century, men streaked out way ahead of women.

In 1945 in Australia, 72% of men and 26% of women smoked. By 1976, men had fallen to 43% and women had risen to 33%.

As a result, men’s tobacco-caused death rates have always been much higher than those of women. Women’s lung cancer rates, for example, seem unlikely to reach even half the peak rates that we saw among men in the 1970s.

Currently in Australia, 15% of men and 12% of women smoke daily.

But what about all the “young girls” you can see smoking, I’m always being told. In 2014, 13% of 17-year-old male high school students and 11% of females smoked. In two younger age bands, girls smoked more (by a single percentage point).

Those who keep on insisting girls smoke more are probably just letting their sexist outrage show about noticing girls’ smoking than their ignorance about the data.

2. Quit campaigns don’t work on low socioeconomic smokers

In Australia, 11% of those in the highest quintile of economic advantage smoke, compared with 27.6% in the lowest quintile. More than double.

So does this mean that our quit campaigns “don’t work” on the least well-off?

Smoking prevalence data reflect two things: the proportion of people who ever smoked, and the proportion who quit.

If we look at the most disadvantaged groups, we find that a far higher proportion take up smoking than in their more well-to-do counterparts have never smoked (39.5% vs 50.4%) – see table 9.2.6).

When it comes to quitting, 46% of the most disadvantaged have quit compared to 66% of the least disadvantaged (see table 9.2.9).

There is a higher percentage of the disadvantaged who smoke mainly because more take it up, not because disadvantaged smokers can’t or won’t quit. With 27.6% of the most disadvantage smoking today, the good news is that nearly three-quarters don’t. Smoking and disadvantage are hardly inseparable.

3. Scare campaigns ‘don’t work’

Countless studies have asked ex-smokers why they stopped and current smokers about why they are trying to stop. I have never seen such a study when there was not daylight between the first reason cited (worry about health consequences) and the second most nominated reason (usually cost).

For example, this national US study covering 13 years showed “concern for your own current or future health” was nominated by 91.6% of ex-smokers as the main reason they quit, compared with 58.7% naming expense and 55.7% being concerned about the impact of their smoking on others.

If information and warnings about the dire consequences of smoking “don’t work”, then from where do all these ex-smokers ever get these top-of-mind concerns? They don’t pop into their heads by magic. They encounter them via anti-smoking campaigns, pack warnings, news stories about research and personal experiences with dying family and friends. The scare campaigns work.

4. Roll-your-own tobacco is more ‘natural’ than factory made

People who smoke rollies often look you in the eye and tell you that factory made cigarettes are full of chemical additives, while roll-your-own tobacco is “natural” – it’s just tobacco. The reasoning here that we are supposed to understand is that it’s these chemicals that are the problem, while the tobacco, being “natural”, is somehow OK.

This myth was first turned very unceremoniously on its head when New Zealand authorities ordered the tobacco companies to provide them with data on the total weight of additives in factory made cigarettes, roll-your-own and pipe tobacco.

For example, data from 1991 supplied by WD & HO Wills showed that in 879,219kg of cigarettes, there was 1,803kg of additives (0.2%). While in 366,036kg of roll-your-own tobacco, there was 82,456kg of additives (22.5%)!

Roll-your-own tobacco is pickled in flavouring and humectant chemicals, the latter being used to keep the tobacco from drying out when smokers expose the tobacco to the air 20 or more times a day when they remove tobacco to roll up a cigarette.

5. Nearly all people with schizophrenia smoke

It’s true that people with mental health problems are much more likely to smoke than those without diagnosed mental health conditions. A meta-analysis of 42 studies on tobacco smoking by those with schizophrenia found an average 62% smoking prevalence (range 14%-88%). But guess which study in these 42 gets cited and quoted far more than any of the others?

If you said the one reporting 88% smoking prevalence you’d be correct. This small 1986 US study of just 277 outpatients with schizophrenia has today been cited a remarkable 1,135 times. With colleagues, I investigated this flagrant example of citation bias (where startling but atypical results stand out in literature searches and get high citations – “wow! This one’s got a high number, let’s quote that one!”).

By googling “How many schizophrenics smoke”, we showed how this percolates into the community via media reports where figures are rounded up in statements such as, “As many as 90% of schizophrenic patients smoke.”

Endlessly repeating that “90%” of those with schizophrenia smoke does these people a real disservice. We would not tolerate such inaccuracy about any other group.

6. Everyone knows the risks of smoking

Knowledge about the risks of smoking can exist at four levels:

• Level 1: having heard that smoking increases health risks.
• Level 2: being aware that specific diseases are caused by smoking.
• Level 3: accurately appreciating the meaning, severity, and probabilities of developing tobacco related diseases.

Level 4: personally accepting that the risks inherent in levels 1–3 apply to one’s own risk of contracting such diseases.

Level 1 knowledge is very high, but as you move up the levels, knowledge and understanding greatly diminish. Very few people, for example, are likely to know that two in three long term smokers will die of a smoking caused disease, nor the average number of years that smokers lose off normal life expectancy.

7. You can reduce the health risks of smoking by just cutting down

It’s true that if you smoke five cigarettes a day rather than 20, your lifetime risk of early death is less (although check the risks for one to four cigarettes a day here).

But trying to “reverse engineer” the risk by just cutting down rather than quitting has been shown in at least four large cohort studies such as this one to confer no harm reduction.

If you want to reduce risk, quitting altogether should be your goal.

8. Air pollution is the real cause of lung cancer

Air pollution is unequivocally a major health risk. By “pollution”, those who make this argument don’t mean natural particulate matter such as pollen and soil dusts, they mean nasty industrial and vehicle pollution.

The most polluted areas of Australia are cities where pollution from industry and motor vehicle emissions are most concentrated. Remote regions of the country are the least polluted, so if we wanted to consider the relative contributions of air pollution and smoking to smoking-caused diseases, an obvious question to ask would be “does the incidence of lung cancer differ between heavily polluted cities and very unpolluted remote areas?”

Yes it does. Lung cancer incidence is highest in Australia in (wait for this …) in the least polluted very remote regions of the country, where smoking prevalence happens also to be highest.

9. Smokers should not try to quit without professional help or drugs

If you ask 100 ex-smokers how they quit, between two-thirds and three-quarters will tell you they quit unaided: on their final successful quit attempt, they did not use nicotine replacement therapy, prescribed drugs, or go to some dedicated smoking cessation clinic or experience the laying on of hands from some alternative medicine therapist. They quit unaided.

So if you ask the question: “What method is used by most successful quitters when they quit?” The answer is cold turkey.

Fine print on this English National Health Service poster states a bald-faced lie by saying that “There are some people who can go cold turkey and stop. But there aren’t many of them.” In the years before nicotine-replacement threapy and other drugs were available, many millions – including heavy smokers – quit smoking without any assistance. That’s a message that the pharmaceutical industry was rather not megaphoned.

Not true. NHS poster.

10. Many smokers live into very old age: so it can’t be that harmful

In just the way that five out of six participants in a round of deadly Russian roulette might proclaim that putting a loaded gun to their head and pulling the trigger caused no harm, those who use this argument are just ignorant of risks and probability.

Many probably buy lottery tickets with the same deep knowing that they have a good chance of winning.

Simon Chapman, Emeritus Professor in Public Health, University of Sydney

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.

 

The slow-burn, devastating impact of tobacco plain packs

Simon Chapman, University of Sydney

It is three years since Australia fully implemented its historic tobacco plain packaging law. From December 1, 2012, all tobacco products have been required to be sold in the mandated standardised packs, which, with their large disturbing graphic health warnings, are anything but “plain”.

Ever since, there have been frenzied efforts by the tobacco industry and its ideological baggage carriers to discredit the policy as a failure.

The obvious subtext of this effort has been to megaphone a message to other governments that they should not contemplate introducing plain packaging because it has “failed”: smoking, it is claimed, has not fallen any faster in Australia after plain packaging that it was already falling before. All that has occurred, they argue, is that illicit trade has increased.

The supreme irony here is of course that if such criticism was correct, then to paraphrase Hamlet’s mother Gertrude, “The tobacco industry doth protest too much, methinks.” Why would the industry and its astro-turfed bloggers waste so much money and effort denigrating a policy which was having little or no impact?

Why take the Australian government to the High Court (and fail six to one) to try and block the law? Why invest in supporting minnow tobacco-growing states such as the Dominican Republic, Honduras and Cuba in their efforts to have the World Trade Organization rule against plain packaging?

Why not just ignore an ineffective policy instead of making it only too obvious to all by such actions that it is in fact a grave threat to your industry?

Two key assumptions have underscored efforts to discredit the impact of plain packaging. First, critics assume the impacts of the law should have been evident immediately as it was implemented: as one colleague put it recently “within ten seconds of the law passing”.

Second, they assume (but never actually state) that the impact of plain packaging on smoking by children (the principal target) and adults was supposedly going to be greater than anything we have previously observed in the entire history of tobacco control.

In 1999, the late Tony McMichael, professor of epidemiology at the Australian National University, published a classic paper called Prisoners of the Proximate where he wrote about the need to understand the determinants of population health in terms that extend beyond proximate single risk factors and influences.

In tobacco control, both proximal (discrete, recent and quick-acting) and distal (on-going, slow-burn) effects of policies and campaigns can occur.
Price rises (and falls through discounting) can have both immediate and lasting effects, jolting smokers into sometimes unplanned quitting and also slowly percolating an unease about the costs of smoking that translate into quitting down the track.

Tobacco advertising bans are a good example of a policy that has such slow-burn effects across many years. Few if any quit smoking in direct response to tobacco advertising bans. They work instead by causing the next generations of kids to grow up in an environment devoid of massive promotional campaigns depicting smoking in positive ways.

I have often heard smokers say “plain packaging won’t make me quit smoking”. This is akin to the myopic self-awareness of those who swear “advertising (for any product) never influences me” while noting that it only influences the more impressionable.

Plain packs were unlikely to act suddenly in the way tax rises do, although the unavoidably huge graphic health warnings may well have acted like straws that broke the Camel’s back of worry about smoking. Their impact was far more likely to be of the slow-burn sort, where the constant reminder that tobacco, unique among all products, is the only consumer good treated this way by the law. It is exceptionally dangerous, with a recent estimate that two in every three long-term smokers will die from tobacco use.

In 1994 I wrote a now highly cited paper in the British Medical Journal which talked about the impossibility of “unravelling gossamer with boxing gloves” when it came to being certain about precisely why smokers quit. I took a day in the life of a smoker who quit, and pointed to the myriad of influences both distal and proximal that coalesce to finally stimulate a smoker to quit.

While a smoker might nominate a particular policy, conversation with a doctor or anti-smoking campaign as being “the reason” they quit, much of what went on before provides the broad shoulders of concern that carry the final attribution. There are synergies between all these factors and the demand to separate them all is like the demand to unscramble an omelette.

So what has happened to smoking in Australia since plain packs?

Data released this month from a national schools survey involving more than 23,000 high school children found smoking rates were the lowest ever recorded since the studies first commenced in 1984 (see graph). This momentum is starving the tobacco industry of new smokers, which is one important reason why all tobacco companies are now busily acquiring e-cigarette brands.

Proportion of 12- to 15-year-olds who smoke, 1984 to 2014

Trends in proportion of current (smoked in past seven days) and committed smokers (smoked on three or more of the past seven days) among 12 to 15-year old students, Australia, 1984-2014. National Drug Strategy report 2014.

With adults, National Accounts data just released show that for the 11 quarter-year periods since March 2013, consumption of tobacco products in aggregate fell an unprecedented 20.8%, while the previous 11 quarters it fell 15.7% and in the 11 before that, only 2.2%.

The latest available data on adult smoking prevalence we have is from 2013 and shows just 12.8% of Australians over 14 smoked on a daily basis. This is the lowest on record and again, the biggest percentage falls experienced since the surveys commenced (see graph).

Reductions in daily smoking among Australians aged over 14, 1991 to 2013

AIHW National Drug Strategy Household Survey 2013: preliminary findings. 2014 Author-sourced.

Meanwhile, the tobacco industry plods along funding heavily lambasted studies which purport to show none of this is happening.

The argument that plain packaging would cause illicit trade to boom was made with monotonous regularity by Big Tobacco between April 2010 when plain packaging was announced and its December 2012 implementation. When the industry lost its case in the High Court, the argument was quietly dropped.

Today, the industry explains illicit trade entirely by the heinous government tobacco tax rises cloaked in a sanctimonious rhetoric of speaking up for poor smokers and corporate citizen concern about tax avoidance bleeding Treasury. In all this it fails to mention that it has long used tax rises as air cover to quietly raise its own profit margins.

As I wrote recently in The Conversation:

From August 2011 to February 2013, while excise duty rose 24¢ for a pack of 25, the tobacco companies’ portion of the cigarette price (which excludes excise and GST), jumped A$1.75 to A$7.10. While excise had risen 2.8% over the period, the average net price had risen 27%. Philip Morris’ budget brand Choice 25s rose A$1.80 in this period, with only 41¢ of this being from excise and GST.

Ireland, the United Kingdom and France have already passed laws to introduce plain packs. Norway and Canada will soon, and New Zealand, Chile, Turkey, South Africa and Brazil have also made high-level noises about joining in too. The world has a lot to thank Rudd and Gillard governments (and particularly Health Minister Nicola Roxon) for taking this initiative, and the subsequent Coalition government for continuing to support it strongly as it continues to come under attack from those it has and will continue to hurt.

Simon Chapman, Professor of Public Health, University of Sydney

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.

A dissenting economist on GST: we should charge more on beer and smokes

Harry Bloch, Curtin University

Recently, 49 prominent Australian economists were polled by the Economic Society of Australia on the issue of GST reform.

Each member of the panel was asked whether they agreed with the following statement:

Increasing government revenue collected through the Goods and Services Tax (GST) by removing exemptions (such as food, health and education) is better than achieving the same extra revenue by increasing the GST rate while retaining the existing exemptions.

Respondents were given five choices ranging from “strongly agree” to “strongly disagree”. The comments were highly varied, but a slight majority of respondents, 54%, chose “agree” or “strongly agree”.

I was among the 11% who chose to strongly disagree.

Among the respondents was Professor John Freebairn, an expert on tax policy. John focusses on the efficiency and equity aspects of the proposed removal of exemptions, arguing that “A broader base and lower rate reduces distortions to the mix of spending choices”.

Not surprisingly, he strongly agrees with the statement that exemptions should be removed, albeit subject to concerns about how the extra revenue is spent including possible compensation for low income groups on equity grounds.

My own comment in strongly disagreeing with the removal of current exemptions is that “it is appropriate for different categories of consumption to be discriminated for (food, health and education) or against (alcohol and tobacco) based on their considered contribution to social well being.”

The design of the GST, including the range of exemptions, was the outcome of a political compromise. In spite of the hyperbole that accompanied the political arguments of the time, the end result did arguably represent the will of the people.

Were people who favoured a GST with exemptions over a tax without exemptions poorly informed or misguided about the efficiency benefits of a broad-based tax over a discriminatory tax (in that it favoured some items of consumption over others)?

Many economists would answer yes to this question, but not me. Critical to my dissent is my view on the proper method for evaluating the benefits society derives from the goods and services consumed.

The standard method in economics for evaluating societal benefits from this consumption is to add up the benefits to each and every individual from their own consumption. Exceptions are allowed where a consumption activity has clear impact on others, such as smoking in an enclosed area. Otherwise, the method implies that government interventions that change the composition of what people consume are distorting in the sense of lowering overall benefits.

Sound good? Fortunately or unfortunately we live in a highly interdependent society. The consumption activities of each of us impact on our family, friends, neighbours and even the society at large. Although these impacts are usually very small, they do add up over large groups.

In this sense, there is a social impact of individual behaviour that often diverges from its private impact. Economists tend to downplay the difference between social impact and private impact, partly because we tend to be believers in individual liberty (“small l” liberals) and partly because economics lacks proper tools to deal with the difference.

So far I have dealt with general concepts; now let us turn to the specifics of the exemptions allowed under the current GST arrangements. Big exemptions, in terms of GST revenue foregone, are for health, education and most food consumed at home.

Using standard economic analysis of supply and demand, exempting these goods and services from GST means we have a healthier and better educated population that spends more time eating at home than would be the case with a uniform rate of GST. Is this good or bad for Australian society?

My fellow economists who agreed or strongly agreed with the statement posed by the ESA think the distortion of individual consumption choices through the GST is bad. Some explicitly mention the use of other methods to achieve socially desired results, but that involves reinterpreting the statement posed by the ESA. I evaluate the implied outcome of more education, more health care and more food at home directly on its merits and I think it is good for Australian society.

This is based partly on my own preferences about the type of society in which I live and partly on my understanding of how education, health and home life contribute to social cohesion. I’ll stop here, for the analysis of social cohesion would take me beyond the usual boundaries of economic analysis and the limits of my own expertise.

Harry Bloch, John Curtin Distinguished Emeritus Professor, Curtin University

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.

 

Cluster bomb of new research explodes tobacco industry lies about plain packs

Simon Chapman, University of Sydney

There is near-universal agreement that Australia’s implementation of tobacco plain packaging in December 2012 has seen the most virulent opposition ever experienced from the global tobacco industry.

While the industry bravely insisted early in its campaigning that plain packs “would not work” their legal actions, campaign expenditure, lobbying and general apoplexy rather suggests they feared it would be a devastating policy, with long term global ramifications.

Indeed, eleven other nations (Ireland, England, New Zealand, France, Norway, Finland, Chile, Brazil, India, South Africa, Turkey) have either legislated plain packaging or are now warming up to do so.

University of Sydney researcher Becky Freeman and I catalogued the full range of industry lies in our recently released (free) book Removing the Emperor’s Clothes. The Cancer Council Victoria has also published extremely detailed rebuttals to the major industry scuttlebutt.

Now today, the British Medical Journal’s specialist journal Tobacco Control has published a special collection of new research which puts further 10,000 watt arc lights on specious industry claims.

Key industry claims have included that plain packs would:

• Drive prices down, as smokers turn away from buying expensive premium brands because they look exactly the same as cheap brands (other than brand names). More affordable cigarettes, they argued, would cause more smoking, including among children
• Flood Australia with illegal tobacco
• Cause smokers to stop buying cigarettes at small convenience stores
• Prompt smokers to use special covers to conceal the large-scale graphic warnings on packs.

Price falls?

One of the new Tobacco Control papers monitors changes in recommended retail prices RRPs from one year before plain packs were introduced until one year after. Prices were adjusted to 2013 prices, and for inflation and average cigarette price stick and grams of roll-your-own tobacco.

The RRPs of tobacco products were higher in real terms one year after the legislation was implemented. Importantly, these increases exceeded increases resulting from consumer price indexation of duty and occurred across all three major manufacturers for both factory made and roll-your-own brands, all three cigarette market segments and all major pack sizes.

Tobacco prices rose most for leading and premium brands 10.0% and 10.1%, respectively) and among packs of 30s (18.3%) and 50s (12.5%). So far from seeing cigarette prices fall across the board, the industry raised prices.

Floods of illicit tobacco?

The tobacco industry’s most common claim was that plain packs would see smokers turn away from buying the purposefully confronting and unattractive plain packs and seek out illegal products not in plain packs.

Tobacco spokespeople made the outrageous claim that about one in seven of all cigarettes being smoked were such illegally obtained cigarettes. Apparently, while ordinary smokers across the country knew where to buy these easily, the full might and resources of the Australian Federal Police could not work out where these were being sold.

Tobacco companies have been proven wrong. Source: Curran Kelleher/Flickr, CC BY

Another study in the collection questioned 8,679 smokers across the country in telephone surveys conducted continuously, from six months before plain packs until 15 months afterwards.

The study found no significant increases in reported purchasing of “cheap whites” (illegally imported Asian sourced brands), of international brands selling for 20% or more less than the normal retail price, or of unbranded loose tobacco (so-called “chop chop”).

Rates of purchase of cheap whites and heavily discounted products were at around half of one per cent of smokers, nothing remotely like one in seven.

Small shops losing customers?

One of the most bizarre claims the industry made was that plain packs would see smokers deserting corner stores for larger retail outlets like supermarkets. This was an appeal designed to tap into wider public sentiment about local corner store owners being crushed under the dead weight of government regulation.

Those making the claim never explained why smokers would abandon small retailers for large ones because of plain packs when the very same packs would be sold in both. Consumer preference for larger retailers is entirely driven by price discounting, something never mentioned in the industry propaganda.

A third paper in the collection examined where smokers purchased their cigarettes. Unsurprisingly, it found no changes from prior to and after the introduction plain packs in where smokers bought their supplies.

Covering up the packs?

In the month that plain packs were introduced, a Queensland small businessman got his 15 minutes of fame from publicity about special pack covers that could block out the unforgettable graphic warnings. Like children covering their eyes from scary scenes in movies, the idea was that many smokers would rush to do the same, outsmarting the hapless bureaucrats who planned the legislation.

A fourth paper which reports on unobtrusive observations of smokers handling their packs in outdoor cafés found that prior to plain packs, just 1.2% of outdoor café smokers used pack covers. This rose to 3.5% in the early months of plain packs and then fell back to 1.9% one year later.

In any event, evidence shows that smokers who actively try to avoid exposure to pack warnings by covering them up, have higher subsequent rates of quit attempts than those who don’t.

Importantly too, these observations recorded that of all café outdoor patrons, one in 8.7 displayed a pack prior to the introduction of plain packs with this reducing to one in 10.3 afterwards. Such a fall is consistent with both a reduction in smoking prevalence and with growing self-consciousness among smokers about showing that they smoke in public.

Impact on adolescents?

There were several principal objectives of the plain packs legislation. But outstanding among these was the goal of making smoking less desirable among young people. This would continue the trend away from smoking, as each successive cohort of children chose not to take up the habit.

A fifth paper used school-based surveys prior to and after plain packs to examine students’ ratings of the “character” of four popular cigarette brands, and variables including perceived harmfulness, look of pack and positive and negative perceptions of pack image.

Positive character ratings for each brand reduced significantly between 2011 and 2013. Significantly fewer students in 2013 than 2011 agreed that “some brands have better looking packs than others” and packs were rated more negatively, with positive ratings decreasing most in smokers.

The tobacco industry and its acolytes can be expected to try to torture these reports to spin yet more denials of the impact it fears will quickly inspire even more countries to follow Australia’s lead.

Australia is fortunate in having some of the very best researchers in the world whose work has contributed to the development of plain packs and now to the evaluation of its impact.

Editor’s note: please ensure your comments are courteous and on-topic.

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.