What the Smokefree 2025 proposals tell us about public health analysis

Submissions on the discussion document Proposals for a Smokefree Aotearoa 2025 Action Plan close on 31 May.

If you hadn't caught the news when it was first announced, the proposals are pretty radical. They include:

• Restrict sales of smoked tobacco products to a limited number of stores
• Introduce a smokefree generation (basically an age purchase limit so that, say, anyone born after 1 January 2004 would never be able to lawfully be sold smoked tobacco products)
• Reduce nicotine in smoked tobacco products to very low limits
• Prohibit filters in smoked tobacco products
• Set a minimum price for tobacco

As Damien Grant so aptly puts it: "It’s presented as a discussion document, but this isn’t really a dialogue. It is a statement of intent." Damien could be wrong. This could be a genuine consultation. But from reading the accompanying materials and from past experience of how these processes work, it certainly feels like there isn't much wriggle room in these 'proposals'. Public health academics, both here and overseas, are basically salivating at the idea that New Zealand is trying something innovative (read: untested) and world-leading (because our government uniquely knows what's best for its citizens).

Besides, as Damien points out, this whole 'discussion' is based on the premise that being a smokefree nation by 2025 is a good thing. The objective is taken as a given. Unfortunately, it is 2021 and Too Late to voice your objections to the goal now.

Because I've previously done some work in this area, I had a squiz at the Regulatory Impact Analysis to see whether there was anything saucy in there. Here's the most horrifying part: I didn't hate it. Someone with more time than me might want to check up on the studies and modelling that the proposals are relying on (and it'd be worth it...some public health papers and modelling assumptions aren't great). As a document though, it looked pretty coherent.

Yet it still didn't feel right. And the parts that don't sit right with me aren't just relevant to smoking regulation which, I believe, is a lost battle. They're not sitting right because I can see the same logic and analysis easily slipping into other lifestyle regulations. They'd fit just as easily into an impact analysis on alcohol regulation, sugar taxes or any activity that offers a dopamine reward (video games, porn, social media). 

There's a problem with how lifestyle regulations in general are analysed.

Lifestyle regulations are too quick to forfeit human capabilities of rationality and reason

The impact analysis claims that 

"It is well established that smoking is both harmful to health and addictive, limiting the ability of smokers to make rational choices to limit this harm."

No one is denying that nicotine is addictive. And most people would agree that addiction can lead to choices and behaviour that are inconsistent with what addicted people want for their long-term selves. But it is a stretch to claim that smoking limits the ability to make a rational choice. It overplays the power of the substance and underplays the human capabilities for rationality and reason. Oh, and it's ridiculously dehumanising and condescending. 

Believing that personal choices don't matter is one thing. Believing that people aren't capable of exercising personal choice is quite the other.

If it truly were impossible to make a rational choice to limit the harm of smoking, nobody would quit smoking ever. Both the motivation and the ability to quit would be extinguished before an individual even tried. Yet people do quit smoking. And people are quitting smoking in droves: at a rate of 8 percent annually between 2017-19. 

A lot of this has been put down to a combination of a heavily punitive excise regime and the opportunity for smokers to switch to vaping as a much less harmful alternative. I don't think these measures changed people's rationality. It simply changed what was the most 'rational' choice.

It does raise the question though: what makes the people who haven't quit but want to quit any different? My doubt the problem is that these people fundamentally lack rationality.

Lifestyle regulations fail to address the real drivers behind an undesirable activity

There will be some people who want to quit smoking but have a lot of other stresses going on in their lives. It's no accident that it is often lower socio-economic groups that struggle most to quit smoking. In its discussion document, the Ministry of Health acknowledges its own research which found that for the cohort of young Māori women,

"services should first focus on the complex mix of challenges and issues that wāhine need to address, in order for wāhine to thrive, rather than emphasising smoking cessation as the most important issue first up. The prototypes used aspirational and holistic wellbeing planning processes with wāhine, rather than plans that focus only on smoking-related goals. The evaluation findings have been applied to all stop smoking services."

This all sounds great. Focus less on smoking as the symptom, and focus more on the drivers that can lead to smoking and make it harder to quit. But (and this is only mentioned at the end of the document) this more holistic approach hasn't even been implemented successfully yet.

That's not to say anything about the known lack of mental health support in this country.

It just seems like such an obvious place to start before introducing costly and untested regulations that are likely to be viewed as punitive by many: how about first making sure the government is doing everything it can to help people deal with the challenges that lead to the behaviour in the first place?

There's no requirement in the Regulatory Impact Analysis to talk about consumer surplus

Consumer surplus (and the ways this is harmed by the proposed regulations) are not mentioned once in the impact analysis. 

Imagine if the government decided that in order to get people to drink less, it wouldn't ban alcohol, but would make it mandatory that all alcoholic beverages must have very low alcohol content and taste like flyspray?

That's what lowering nicotine and removing filters will do to the experience of smoking. Yet nowhere in the analysis is it acknowledged that these proposals fundamentally change the enjoyment of an experience. In public health analysis, removing the enjoyment from an activity gets counted as a 'benefit' because it helps the government achieve its objective.

Costs to businesses are counted and could capture at least some of this harm, as people consume less of the product (which in turn counts as a symmetrical benefit for meeting health objectives). But nowhere is the diminished enjoyment of an activity considered.

To me, that's where I start getting worried about this approach slipping into other lifestyle regulations. Why not dramatically reduce the sugar content of all foods so they taste terrible but are significantly healthier? Have plain packaging for alcohol so that the expensive wine you brought to a dinner party looks the same as an $8 bottle? Or require internet service providers to send a notification to the user's mother or partner before accessing porn? 

Without considering how a regulation can change the personal benefits individuals enjoy from a given activity, the analysis inevitably seems rather slanted. With lifestyle regulations, this is particularly important as it naturally impedes on personal choice and freedom.

And so, with lifestyle regulations, we are likely to end up with many more Regulatory Impact Analyses that look OK because they meet the stated objective but feel really, really bad.

What about the kids who don't want a free healthy school lunch?

Jamie Oliver will forever be remembered amongst some Brits for getting the beloved turkey twizzler banned from school lunches. 

One of the best ever moments of food television was the time Jamie Oliver tried to shock kids out of their love of chicken nuggets with some slasher movie-esque imagery. It was high drama TV. He chopped up and minced all the gross bits of a chicken  (lots of ewwws from the children) and chucked some breadcrumbs over them. I'm surprised he didn't go all in and slaughter a chicken in front of them too. He then asked the kids how many of them would still eat the chicken nuggets.

Except, he forgot one thing in his cunning plan: kids will be kids.

The result?

The kids enthusiastically confirmed that they would still eat the chicken nuggets. Jamie Oliver was devastated. God I love the honesty of kids. And chicken nuggets, for that matter.

I bring this up in light of New Zealand's own healthy lunches in schools programme -Ka Ora, Ka Ako- where it has been recently revealed by Stuff that thousands of free healthy lunches are rejected by students each week. 

Even more disturbing, it has been reported that according to the Ministry of Education, no-one is responsible for counting the number of rejected lunches.

Now, talking about free meals in schools is almost intrinsically linked to talking about child poverty, and it is certainly the Children's Commissioner's view that free lunches in schools should be a birthright. Being against free school lunches must mean that you are pro child poverty, right? 

But there's another angle to this: what if some children don't want these free lunches? And shouldn't this be an important part of the evaluation of such a programme? There is supposed to be an evaluation, by the way. But the fact it sounds like data on rejected lunches isn't being collected makes me think this isn't part of the evaluation (happy to be proven otherwise!). 

Now, as far as food wastage goes, the programme is not a complete bust. The rejected lunches at least get donated. But the to-and-fro between Act's David Seymour and the Minister of Education Chris Hipkins is revealing.

David Seymour argues:

“If you’re responsible for sending out taxpayer money, then you’ve got a duty to measure its effectiveness, not just for the taxpayer, but for the kids...If you really care about them, and they’re sending back 500 uneaten lunches, you want to know why.”

Hipkins responded 'it would be “nanny-statish” for all schools or providers to monitor the number of uneaten lunches.'

“If David Seymour wants to be the lunch monitor in every primary and secondary school he's welcome to do that.”

Except....it kind of sounds like schools are already expected to play the role of lunch monitor. Here's the Ka Ora, Ka Ako guidance for schools to encourage participation in the programme.

Cards on the table here: I was a terribly fussy eater as a kid. I thank my parents for being pragmatic enough to concede that it was better for me to eat something for lunch that I chose, rather than nothing. So I  find the guidance deeply and personally horrifying. 

Rewarding positive eating behaviour? That doesn't sound particularly bad. But as a shameless teacher's pet, I really liked positive reinforcement and would feel bad if I didn't get it. I sure would have found it distressing if I had to not only perform well in class, but eat well during my lunch break too. Is it really the role of the teacher to enforce such personal lifestyle habits? There are so many opportunities in the course of an average school day to feel bad about yourself and that you're weird or dumb or wrong, do teachers really need to make lunchtime part of that experience too?

Or how about the suggestion that children be 'encouraged' to try new foods. Encourage sounds suitably benign. But not all kids would feel comfortable telling their teacher -the person of highest authority- that no, broccoli looks and smells awful and they will not be trying one bite.

And as for the expectation that children with packed lunches be forced to wait 10-15 minutes before tucking into their lovingly home-prepared meals they may prefer, well, that just sounds mean. That seems like a very deliberate attempt to make kids feel like their home brought meals are inferior. 

I'm not even going to comment on the suggestion that "healthy food tastes better if you are hungry", but please imagine me silently tearing my hair out. Actually, I can't not comment: is...the guidance suggesting schools starve the children in order to trick them into thinking healthy food tastes nice?

There has got to be a place for agreeing child poverty and starving children is actually bad, but also wanting to know whether the free lunches programme is well targeted and working as intended. It seems like a pretty reasonable expectation before demanding the programme be rolled out universally.

And as for the guidance to encourage kids' participation in the programme? Sounds a bit nanny state-ish to me.

Lessons from Australia's culture wars

Sometimes even when I don't love a book overall, there will be certain ideas or sentences that stick with me. That alone makes it worth the read. Here are my notes in the margin for one of those books (mental notes by the way: only a monster would write on a library book). And boy, a lot of it is timely and relevant to free speech conversations happening here in New Zealand. So let's get straight into it.

Truth is trouble, by Malcolm Knox

What perspective is the author coming from?

I...honestly couldn't say? I didn't Google the author to find out whether he's been cancelled or not, so I'm judging the book purely on its merits. The book is written in a mostly fair and balanced way, not overly left or right. There were some descriptions of the Church that could have been handled in a more sympathetic manner by a different writer. But all in all, I didn't feel like I was being taken on an ideological ride. If you're wanting something comprehensive and academic, this ain't it. But if you're interested in hearing non-academic voices in the free speech conversation, this hits the spot. 

Is the book worth reading?

I'll be honest, I read this book in two sittings, but it still could have been a lot shorter. I found some chapters superfluous and some anecdotes ran a bit long. If you're an impatient reader, that could put you off. 

I'm going to say yes, this is worth reading if you're a New Zealander interested in understanding the free speech issues our neighbours have grappled with. The book is very current (published late 2020) and references how the culture wars played out in the pandemic. I'll be covering off the key themes and quotes that stood out to me in this post. 

The role of the ambivalent centrist

One thing I like about this book is the author's honesty about his own ambivalence. About not having real skin in the game. It's not necessarily a virtue, as he himself acknowledges. Some people are personally affected in free speech debates, whether they choose to be or not. But Knox raises an important question:

"Is the proper response of those disengaged from personal experience to stay silent?...Should the moderate, the sceptic, the unconvinced, the neutral, simply let the fight happen elsewhere, as if the polite response to a scuffle in the pub, say, is to keep on drinking and let the brawlers tear down the walls?" (p.6)

The implication, of course, is that only the loudest and extreme voices dominate the debate. The challenge is figuring out how to enter the debate when you don't have a strong opinion.

I don't know what the ideal solution is. Both the media and social media thrive on pithy soundbites. As someone broadly concerned about the protection of civil liberties, I worry that freedoms and protections (including the right to feel safe from violence) will be eroded while I'm still deep in ponder. And yet it is the hasty, gut-driven approach that is likely to lead to worse outcomes for all. There's an element of game theory to all of this. Or to put it another way, a panic buying toilet paper situation.

My only real opinion for what this means for New Zealand is a plea to slow the hell down. There will always be some who jump the gun, but we didn't run out of toilet paper and we're not going to lose our civil liberties and protections overnight unless enough people expect the worst of their fellow Kiwis.

Minorities suffer from free speech restrictions too

This point wasn't handled particularly convincingly in the book, but it's definitely worth noting. To what extent do free speech restrictions reflect and entrench existing hegemonies?

A lot of people like to talk a big game when it comes to diversity, but when it comes to a genuine plurality of opinions, how much 'free speech' will be tolerated if it goes against the dominant cultural and social values? 

Many free speech restrictions are, of course, intended to protect minorities. But 'minorities' isn't just one group with the same values and needs, and even within minority groups there are sometimes opposing viewpoints.

The role of employers in enforcing free speech restrictions

Well, this is extremely timely given New Zealand now has a registered union dedicated to protecting free speech.

On the one hand, it is a private contractual issue: if you voluntarily sign up to a code of conduct or social media protocol then you are obliged to stick to it. Don't like the terms and conditions of employment? Look for a better job. On the other hand, should employment terms and conditions be applicable even when the worker is 'off the clock'? And should those obligations trump the right of freedom of expression?

The incentives matter here too. Employers are naturally risk averse and reputation-oriented. If enough people demand action from an employer to sack an employee, then this is the much easier road to take rather than stand by the employee's private life. There are proper disciplinary and termination processes that employers have to follow, but once you're down that path, the employment relationship is likely already broke.

And then there's the asymmetry in power. Employers can make whatever public stance they like without consultation with employees. But what happens if that public stance on, say a political or social issue, goes directly against the employee's private religion or beliefs? As businesses increasingly do issue stances on social issues and are seen as vehicles for social action, this isn't just a hypothetical.

The book could have just started and ended here. Want to know why moderate voices don't speak up on free speech and other controversial issues? Because they don't want to get fired. Because they just want to live a simple life that includes employment. End of story. Not a satisfying ending, but this is surely a huge deterrent. 

Where does freedom of religion fit into this?

I feel I'm too far detached from any church or religion to get a good sense of what the views on religious freedom are in New Zealand.

In Australia these views have been thoroughly thrashed out in several public inquiries (four inquiries in two years) including a public inquiry into whether Australian law protected rights to religious freedom which attracted more than 15,500 submissions.

Here's the upshot:

"A deep dive into the inquiries showed that while religion might be a fading force in Australia numerically, it's capable of causing as much heated division as ever. What it is losing in numbers, it is making up for in passion...When I looked closely at those wanting to influence the religious freedom bill, both for and against, whatever their differences in relation to religion and freedom of speech, the sense of grievance and endangerment was common." (p.188)

I've sampled both sides of submissions on this issue and feel that both sides put forward compelling cases in the name of freedom and protection from hate and discrimination. I suspect that a fulsome conversation on free speech laws in New Zealand will yield similar results. What happens then? Do you pick protect one minority over the other and accept there will always be an aggrieved party? Do you declare an impasse and conclude the State simply cannot decide? 

What seems to be clear from the Australian example is that these conversations are likely to be ongoing. Indeed, if neither side felt endangered there would be no need for a culture war.

Protect the place for subtlety

"If you try to be clever or ambivalent or subtle or anything less than absolutist, you are prone to being misheard. Unless you are plain and literal, unless you raise your voice into a plain and literal shout, then your words will only be twisted out of shape and turned back against you." (p.197)

I hear this. As someone who enjoys words and playfulness and occasional satire, this hit hard. We're in an online environment where tweets get quote tweeted, or sentences get pulled from a blog or wider piece of writing out of context. It doesn't matter what you stand for, or what your track record on an issue is. In the hands of strangers, your words are no longer yours.

And yet, offline New Zealand does not seem to have the hardened tribalism we see overseas. There's still a place for reasonable debate on most issues (although I can think of some notable exceptions). We don't want to lose that. 

If the culture wars here do rise from a trickle to a flood, it will come at the expense of being able to be heard on your own terms to people who aren't on your "side". 

We must continue to protect the ability to be heard fairly. It's not a right. But it is surely an end worth striving for. 

Are cultural and social issues dwarfing economics?

An alternative title for this post could have been 'Economist ennui: how to keep things fresh when you've been talking about the same ideas for the past 20 years'. But that sounded a bit bleak, even for a post on economics.

There's something in the idea though, that there are certain social and cultural issues that appear to be dwarfing economic issues. Or at the very least, there are things happening in society that economic frameworks alone can't help us understand. If I had to pinpoint a day when these ideas started gnawing at me, it would be March 15 2019. Suddenly, a lot of previously important issues seemed small. And the issue of wtf is happening in society that I haven't been paying attention to seemed really, really big.

As it turns out, I'm not the only one feeling a shift in attention.

Let me introduce you to two of my favourite economic commentators: Russ Roberts at the podcast EconTalk and Tyler Cowen at the podcast Conversations with Tyler and blog Marginal Revolution. If you're into interesting economic commentary and haven't yet tuned into these podcasts/Tyler Cowen's blog, you can thank me later for making your life infinitely better. Both economists are excellent at what they do.

Anyway, Roberts and Cowen recently did a podcast on revisiting pandemic predictions, although as is typically the case, the conversation was wide-ranging. The bit on the podcast that made me pause my ironing is as follows (edited down for brevity):

Russ Roberts: ...You know, 10 years ago if you had asked either of us what are the big issues, we would have given a very traditional response. It would have been the same set of issues that I think we would have given 20 years ago: size of government, the role of prices, deregulation versus more regulation, and so on. 

I feel we're at a moment in world history now where those concerns seem dwarfed by cultural issues. I've become personally much less interested in, say, whether Modern Monetary Theory is really true. I think it's not. But, I'm less interested in that issue than I would have been 10 years ago. And, I'm much more interested in the cultural consequences of public policy. The impact on human dignity. I'm much less interested in efficiency and growth--the things that I know you've championed. Have you had any of that kind of reconsideration? 

...you've been a champion of economic freedom, as I have been, of the importance of growth as I have been. I'm less excited about those issues. I'm more interested in some of the more cultural issues. Has that happened to you at all? And, if not, tell me why I'm making a mistake.

Tyler Cowen:...I don't view economic growth as any less important. In fact, the higher our debt is, as we were saying before, the more imperative it is to grow to pay it off. I'm not sure how much more I will write about that, as I feel I've already said a lot of what I have to say about growth. 

To me, a key question now is the cultural effects of the internet. It allows people to be much weirder, which is a significant positive, but also pretty often a significant negative. And, in my view it's not polarization: It is weirdness. It's a very different concept. And, we're misunderstanding it. 

So, to think through how that's going to work is maybe the question I think about the most right now and that's very much along the lines of what you brought up. And, it was not something I thought about nearly as much 10, 15 years ago.

Note here that neither economist is saying that economic issues don't matter, or that they are any less important than they once were. What I got from that snippet is that there are other things happening in society that everyone, including economists, should be paying attention to and making an effort to understand as well.

And it doesn't have to be one or the other. Where Roberts talks about the cultural consequences of public policy and the impacts on human dignity, economic frameworks can both inform better public policy responses and help understand the likely impacts.

On a purely practical note, it's also worth sympathising with the fact that anyone, including economists, would get bored of talking about the same thing for at least the last 20 years. Understanding new phenomenon keeps both the individual mind, and the wider profession, fresh.

All of this points to the importance of thinking and reading widely. Insights on culture can be found everywhere: autobiographies, anthropology, philosophy, history, psychology (just make sure it survives the replication crisis), podcasts, foreign films and television, social documentaries, even talkback radio. 

In the early years of my career, I thought that reading or watching anything that wasn't politics or economics focused was a luxury. That turned out to be a mistake. Knowledge, and more importantly intellectual curiosity, can come from the most unlikely sources. Some of the most gripping social and political insights I've had have been sparked by fictional narratives that moved me into caring about the thing in the first place. On that note, Joe Ascroft has a great piece over at The Blue Review on the conservative underpinnings of Paddington 2, if that's your thing.

Of course, the best economists I know already do read prolifically. In fact, it was the economists who read widely and often outside of their discipline that had the most interesting and insightful things to say early on in the pandemic. All because they didn't treat it as an economics-as-usual event. 

I think the new thing I got from this podcast snippet was permission to follow your nose. To let yourself get curious and excited about social and cultural issues. These aren't just interesting side hobbies, these are the things that shape the world we live in. I normally hate the perception that men are drawn to hardcore macroeconomics and women are drawn to touchy feely squishy stuff. However, if that were true (I don't think it is), perhaps in the future it will be female economists who can provide more fresh, insightful and relevant economic commentary.

It's also a relief to feel like I have permission to be bored of endless commentary on how to fix the housing crisis, the effects of minimum wage increases and rent controls, or the best monetary policy theory. It's not that these things don't matter, they still do, and someone needs to talk about them. 

But if it feels like you've heard it all before, it's not your imagination.