Similar interventions implemented via GSN apps may be protective against substance misuse among GSN appusing MSM. Finally, those interested in promoting health behaviors among GSN app-using MSM must bear in mind that GSN apps are used for much more than substance use and/or casual sex partner seeking; instead, GSN apps represent important social contexts for affiliation between gay, bisexual and other MSM. Recognition of the important social role that GSN apps play in the lives of MSM will assist public health practitioners to develop interventions that promote positive affiliation while reducing high-risk behaviors.Policymakers seeking to present a logically justifiable regulatory system for tobacco may want to consider policy coherence, integration, and proportionality. The concept of ‘policy coherence’ suggests that various policies related to an issue are mutually reinforcing. The coherence can be across jurisdictions ,1 across agencies or arenas , or across the broader spectrum of substances . Maintaining consistency may involve ‘policy integration’, in which all substances are regulated by the same agencies . ‘Policy proportionality’ ensures that substances are regulated in according to the harm or risk they present. One way of approaching tobacco policy coherence, integration, and proportionality would be to regulate tobacco as part of a continuum of addictive or psychoactive substances that cause varying degrees of harm. Currently, plant bench indoor in many countries some substances are criminalized and some are legal but controlled in multiple different ways , often by different agencies.
Regarding coherence and integration, taxation of tobacco, for example, is often not administered by health agencies, and the rate is rarely at levels recommended from a health perspective. Proportionality is also an issue. Tobacco is addictive, kills more than half its users, and impairs the health of others. Alcohol is addictive to some and can lead to abuse and both short term and long term health problems, as well as indirect harms , but may also be used unproblematically. Marijuana may be addictive for some, but can also be used for medical purposes or recreation without harm. In the state of Virginia tobacco sellers are not licensed; spirits are sold only in state operated stores and beer and wine retailers must be licensed; and possession of marijuana is criminalized. This incongruence allows the most dangerous substances to be the most widely available. A more coherent, integrated, and proportional policy approach to tobacco that has been raised – but not yet analyzed – is to limit tobacco sales to government-controlled outlets. This approach could be used by any jurisdiction, but would be most practical for those that already have – or are considering instituting – such outlets for other substances, such as alcohol or marijuana. Internationally, some 15 countries already have government retail monopolies for alcohol, and Hungary recently established such a system for tobacco, though it does not have one for alcohol. Uruguay decriminalized marijuana with the intention of establishing government dispensaries; however, this part of the law remains to be implemented. In the U.S..
Federal law permits state or local governments to regulate or prohibit the sale of tobacco products, and the 2014 U.S. Surgeon General’s Report mentioned sales restrictions as a possible endgame strategy. Several jurisdictions in the United States may be ideally situated to implement such a measure, as they have already established government retail monopolies for alcohol. Some are contemplating adding marijuana to the mandate of their alcohol control systems. Other states, currently without alcohol control systems, are considering such systems for marijuana. Moving tobacco sales to government-operated stores could facilitate better congruence between the potential harm of substances and their regulatory status and movement toward a tobacco endgame. This paper analyzes potential advantages, challenges, and disadvantages of such an approach to tobacco control, focusing primarily on the US although in most respects the analysis could be applied in any jurisdiction.Although currently alcohol, tobacco, and marijuana are all considered psychoactive substances with varying potentials for harm, addiction, and abuse, historically they were regarded as very different from one another. Thus in the US lawmakers placed them in different regulatory systems. Early in the 20th century, concerned primarily about unregulated use of opiates and cocaine, the U.S. Congress and the states established anti-narcotics laws. Marijuana was gradually included in these laws due to a confluence of factors, including its association with poor and working class Mexicans . Regulators and the popular press claimed marijuana was highly addictive, caused users to commit violent crimes, and ultimately resulted in insanity and death. By the late 1930s, nearly all states prohibited marijuana sales and use; this was followed by Federal legislation. However, in the 21st century, numerous states have loosened regulations to allow for medical or recreational use of marijuana.
Tobacco, specifically cigarettes, was a target of social reformers in the U.S.. Numerous states passed laws prohibiting cigarette sales in the years before World War I. The war transformed cigarettes from a symbol of moral weakness and dissipation to one of soldierly manliness. By the end of the 1920s cigarettes were legal for adults in all states. The Food and Drug Administration’s enabling legislation excluded tobacco from oversight and tobacco products remained unregulated at the federal level until enactment of the Family Smoking Prevention and Tobacco Control Act in 2009. Internationally, the situation is similar to that in the U.S., with different jurisdictions having varying restrictions on use , licensing for sale and age of purchase, and packaging, but little regulation of the product which is almost universally legal for adult use. As with marijuana, an unfortunate association arose between immigrants and problematic use of alcohol. After many years of temperance advocacy with some success in the states, the US ratified the Eighteenth Amendment to the Constitution in 1919. It prohibited manufacture, sale, and transportation of alcohol and came to be known as ‘Prohibition’. Its repeal in 1933 returned alcohol policy to the states. Those that chose to regulate it then established state monopolies for alcohol sales at the wholesale or retail level; most other states developed license systems. Twelve states continue to have governmentally-operated retail outlets. Others have abandoned the control-store approach in favor of licensing . The alcohol industry advocates privatization and has used referenda, legislation, and litigation to achieve it.16 In the twelve alcohol control retail states, however, the state stores model limits the number of liquor outlets. As Table 1 shows, where measured, tobacco outlets per 100,000 population far outnumber alcohol outlets in such states. In terms of regulatory policy coherence, integration, and proportionality, there is no public health justification for maintaining the vastly higher density of tobacco outlets. Adoption of a government tobacco monopoly could contribute to a broader ‘endgame’ strategy – one specifically designed to change or eliminate permanently the structural, political, greenhouse rolling racks and social dynamics that sustain the tobacco epidemic– to end it in a specific jurisdiction within a specific time. Achieving an endgame is now a national goal in Finland17 and New Zealand, for example, although they do not have specific, concrete plans for achieving this goal. The 2014 US Surgeon General’s report on tobacco use suggested consideration of bans on tobacco sales at the city or state level as one option for achieving a tobacco endgame. A recent sales ban in Massachusetts was, however, quickly rescinded after public protests. Thus, it may not be feasible to move directly from allowing cigarettes to be sold virtually everywhere to prohibiting sales altogether. Instead, an endgame, like other tobacco control policy innovations, will likely involve a variety of incremental approaches in multiple jurisdictions. A state tobacco monopoly could be one such approach.Policy change is more feasible if it incrementally builds on existing policies, coordinates problem definition with political and policy initiatives, and serves to advance multiple governmental objectives. Personnel at government alcohol stores already enforce age of purchase rules. If jurisdictions established the same age limit for alcohol and tobacco purchases such verification systems would be simple to implement. If marijuana is legalized, the existing system of alcohol stores could sell those products as well.
A transition of tobacco sales to government stores could promote more coherent policy for regulation of legal substances whose use causes social harms. Because the government would retain all profits from sales, moving tobacco sales to government-operated alcohol outlets should be economically feasible. Costs would consist primarily of creating display and storage space, training personnel, and purchasing products. Governments could negotiate wholesale terms and set retail prices high enough to discourage use while covering costs. To mitigate objections from tobacco retailers, governments could create a ‘transition fund’ from tobacco revenue– to provide retailers a one-time or multi-year payment based on their usual tobacco profits. These funds would enable retailers to reduce reliance on tobacco sales. As tobacco consumption continues to drop, they would need to do this anyway. Government stores could facilitate information gathering about profits from tobacco sales. This could assist other governments attempting novel retail policies. Reduction in outlets would allow funds currently used for surveillance and enforcement of age of purchase laws to be redeployed for public education about and enforcement of the ban on sales by private retailers. Compliance checks for a smaller number of government stores would be easier to conduct regularly. Nearly ubiquitous availability of tobacco 22 contributes to misperceptions that tobacco is a normal consumer product and undermines public health messages. Moving sales to existing government-operated alcohol outlets would signal that tobacco products are dangerous and require special measures. It would also give governments maximal control over multiple policy instruments. Governments could limit or eliminate point of sale advertising or display, limit the range of brands or products for sale, refuse to sell flavored or menthol products, sell only one variety per brand family, or set purchase limits to reduce secondary illegal sales to minors. These measures could be undertaken incrementally to allow time for consumer education. Selling tobacco in government stores only would also limit the hours of sale and the density and location of tobacco outlets. Currently, when governments raise tobacco taxes, the industry either temporarily lowers prices to minimize the quit attempts that a sharp price increase can inspire, or increases prices to maximize profits while suggesting to consumers that the price increase is due to the tax. A government tobacco monopoly would neutralize both responses. Any increase in price redounds to the good of the government. Pricing policies might be constrained by tobacco prices in neighboring states or countries, particularly in border areas. Establishing a government tobacco monopoly could reduce relapse and smoking initiation by making products less available and visible. Tobacco outlet density has been positively correlated with smoking status, youth and young adult initiation; exposure to cigarette retail displays undermines quit attempts. By contrast, alcohol monopolies reduce consumption and alcohol-related problems; in the U.S., alcohol control states consistently have lower alcohol consumption per capita than non-control states. Fewer high school students in monopoly states than those in non-monopoly states report drinking alcohol in the past 30 days or binge drinking in the past 30 days. Selling tobacco in government stores would also likely reduce sales to underage youth. As government store employees, clerks would be accustomed to performing age checks for all purchases . Increased compliance checks would make risking illegal sales less appealing. As government store employees, clerks would not be motivated by the potential profits to be made by underage sales, as owners or operators of small stores might be. Challenges and Potential Concerns A major challenge to implementing such a policy change will be the tobacco industry’s political influence and ability to mobilize opponents. The tobacco industry would be likely to mobilize political actors such as convenience store associations and ‘citizen’ front groups to oppose the measure. Tobacco sellers in France have been strong opponents of tobacco control measures they perceive to affect their profits. Some objections from retailers might be assuaged by the transitional payments discussed above, but we must acknowledge that stores will be unable to sell a profitable item that brings in customers who may make other purchases. Developing retailer and public education programs with effective messaging would be essential, and this could require additional expenditures. There might also be opposition to the initial costs .