COVID-19 has claimed close to 9,000 lives in Malaysia at time of writing. No doubt, this pandemic has crippled the national economy and disrupted the livelihoods of the rakyat. But there is another kind of peril that kills more people every year and is a destructive force against society.
According to the Health Ministry, smoking kills about 20,000 Malaysians every year. The Tobacco Atlas, an initiative of the American Cancer Society, thinks the number is higher. It says that more than 27,000 Malaysians die of tobacco-caused diseases every year.
In fact, tobacco kills nearly six million people a year worldwide, including more than 600,000 nonsmokers who die from exposure to tobacco smoke, according to the World Health Organisation. This is higher than the 4.2 million lives that Covid-19 has claimed globally thus far.
Despite smoking being a health hazard, recent government action on tobacco use is not aligned with health outcomes. It prioritises revenue generation from tobacco tax with a secondary trickle-down effect on public health.
In Budget 2021, measures against tobacco use and smoking falls under the Finance Ministry’s objective of “sustainability of government revenue” in an “expansionary budget”. The goal is increasing collection into government coffers and the tactic is punitive measures. This should not be the purpose of public policy.
Tax derived from licensed tobacco manufacturing and import is about RM4.15bil. What the Finance Ministry hopes to recover – encouraged by tobacco lobbyists – is tax revenue lost to illegal cigarettes (ie, those smuggled into the country) that is estimated at RM5bil per year. This requires added expenditure on enforcement activities and second-order costs of conviction and detention of smugglers. It was exactly what the multinational tobacco giants had lobbied for in the months before the budget was revealed in November 2020.
The measures in Budget 2021 are aimed at cutting off the availability of cheap contraband cigarettes. Without this alternative, smokers can only buy cigarettes that have been subject to tax. Their higher price is meant to deter smokers.
Steering smokers towards legal forms of “sin” seems like a convoluted way of achieving social wellbeing. It downplays socioeconomic costs. Also, government policies that rely heavily on regulation and enforcement invariably present opportunities for abuse and corruption by those who are unscrupulous. And if the policy doesn’t meet its target, health outcomes and societal wellbeing suffers.
A behavioural approach
A better approach is to address the problem through behavioural change. This is where we focus on the intent and action of the smoker and their families. It’s the pull, rather than the push factor.
This approach is known as behavioural insights and is recognised as a public policy lever and economic instrument in nudging people towards behavioural change.
Behavioural insights came about through an evolution of economic theories by Nobel laureates like Richard Thaler (2017), Daniel Kahneman (2002), Abhijit Banerjee (2019), Gary Becker (1992), Herbert Simon (1978) and others.
Many countries, such as the United States, United Kingdom, Netherlands, Australia and Singapore have behavioural insights units within government to help make public policies that are designed around people. They use behavioural interventions to nudge public responses to government policies.
In the case of smoking and other noncommunicable diseases (NCDs), the government should look towards behavioural therapeutics. This is where people selfdiagnose and manage their own health.Devices and software applications to monitor and manage our health and personal wellness are becoming cheaper and simpler to use. This lessens the burden on hospitals and medical facilities, at least for routine healthcare maintenance.
A good example is the oximeter, readily available through local e-commerce sites. People use it to test the oxygen saturation level in their blood, to check for heart disease, lung cancer, pneumonia, asthma and even Covid-19. The point is that people are already using devices and test kits to selfmanage their health. These devices and kits work best alongside behavioural nudges and guidance from medical professionals.
Malaysian startups, such as Naluri and BookDoc, and apps, like Pulse by Prudential Assurance, already use behavioural interventions for healthcare. They create timely nudges around a feedback loop of health indicators. They guide positive behaviours through social networks, so that good health becomes a social norm.
In fact, the Covid-19 pandemic has demonstrated the importance of behavioural change among the public. While regulations and enforcement of SOPs by the authorities are still needed, without cooperation and self-regulation by the public, it would be harder to curb the spread of the virus.
Public policies based on people
Government policymaking must take into account the public’s behaviours and responses. To this end, the Economic Planning Unit is encouraging both government and industry to use behavioural insights to craft smarter policies when it involves the public.
Nudging behaviours does not cost much and can easily be adjusted according to public response. If a nudge is successful the government saves money on healthcare (and other public expenditure), and saves money on enforcing against illegal activities. The revenue gained from tobacco tax therefore is no longer important. It should never have been a policy goal anyway.
At its core, good government is about economic progress and societal wellbeing. However, most government policymaking has long been rooted in an old economic model that has existed for over a century – one that is reliant on incentives and penalties, and regulation and enforcement. On the other hand, Big Tobacco has understood consumer behaviour since the 1950s, successfully using messaging that has made smoking desirable.
The good guys need a game changer! It is time to turn the tables on smoking through behavioural insights.
Eddie Razak is a consultant on social development and behavioural insights. He studied government and public policy at the Harvard Kennedy School, United States, and the Lee Kuan Yew School of Public Policy, Singapore.