Manager, Quit SA
Tobacco control has been a top priority for cancer control in Australia for at least four decades. The first firm evidence of the connection between smoking and lung cancer was published in 1950 and greater impetus to the level of knowledge and concern was provided by the first US Surgeon General’s report in 19641 and the British Royal College of Physicians report in 19622. It has been a hard slog ever since, because tobacco use is so entrenched in social and cultural practices, the tobacco industry has mustered so much influence and the medical and public health lobby has been so weak by comparison.
The pace of progress on tobacco control accelerated in the mid-1990s with the collective assault on big tobacco by most of the US state governments to recover health costs related to treating smokers, resulting in the Master Settlement Agreement. Although the settlement has many problems, it has at least forced the tobacco companies to agree publicly that smoking is harmful to health. With increasing pace of litigation, it is now possible to begin to imagine the “end game” for tobacco, although it may be still many years or decades off.
One sign of this is that tobacco is now recognised as a global problem. The World Health Organisation (WHO) estimates that the annual death toll from tobacco is 4.9 million and rising. To increase the global effort to reduce this epidemic, the WHO has lead the negotiation of the first international treaty on health – the Framework Convention on Tobacco Control (FCTC). The Australian government and NGO delegations played a strong role in the negotiations. Australia is currently completing the formalities to ratifying the treaty and when 40 countries have ratified it, the FCTC will enter into force. Although it is not expected to have a big impact on Australian tobacco control measures, it will substantially strengthen action in many other nations in our region, such as the island nations of the Western Pacific where tobacco control is often weak.
Australia’s first National Tobacco Strategy (1999-2004), a partnership between state, territory and federal governments, helped to give some coherence to tobacco control activities. The National Expert Advisory Committee on Tobacco (NEACT), chaired by Professor David Hill, has played a key leadership role in the national strategy. Unfortunately NEACT has now been abolished and there is no clarity about how leadership will be provided for the new five year strategy, now under development.
Michelle Scollo, co-director of the VicHealth Centre for Tobacco Control, has been the driving force in the development of a compelling economic case for increasing investment in tobacco control by Australian governments. Tobacco Control: A Blue Chip Investment in Public Health3 has been promoted to policy makers, with little visible impact to date. The Commonwealth Government has budgeted $5.16 billion income from tobacco taxes in the next financial year. On the other side of the ledger, it spends a meager $2 million on the National Tobacco Campaign. State and territory resourcing varies considerably, but most states exceed that expenditure on a per capita basis, with Victoria, South Australia and Western Australia doing best. The combined Commonwealth and state investments are all well below the $10 per capita recommended by the Blue Chip manifesto.
Australia has a strong regime to control advertising of tobacco in the media and through sponsorship. The Commonwealth Tobacco Advertising Prohibition Act, in combination with state legislation, has eliminated most obvious forms of promotion, except at the point of sale. The tobacco industry has responded by devising new methods of promotion. Event-based marketing and buzz marketing at youth venues such as nightclubs, rock concerts and rave parties are notable examples. Jane Martin describes these in her contribution to this issue.
Portrayal of smoking in films and television is at record levels in both imported films and local production and there is clear evidence to show that this increases the risk of young people taking up smoking. The Tobacco Advertising Prohibition Act is currently under review. The Cancer Council Australia in alliance with other groups made extensive submissions on these and other issues that need changing. The outcomes of the review are expected to emerge before the end of 2004.
Health warnings on tobacco packs are the most direct way of informing smokers of the harm that smoking does and action they can take to quit. Current warnings were introduced in 1995 and have clearly lost their impact. Pictorial warnings with high impact were introduced in Canada in 2000 and a similar regime is to be implemented in Australia in 2006. The warnings will take up 30% of the front and 90% of the back, rather than the 50% of both the front and back favoured by health groups. The Cancer Council’s two submissions on these matters can be seen at www.cancer.org.au. Ron Borland explores the issues around pack warnings and the role they can play in more detail in his article, Role of Information on Packages in Tobacco Control.
If cigarettes could be made safe, instead of causing the death of half their long-term users, there would be no need for all this effort. If cigarettes could be made safer than they are at present, then presumably the burden of disease they cause might at least be reduced. Caution is needed here, since there have been at least two previous innovations that promised much, but delivered little. The first was the introduction of filters. Smokers rapidly switched preference to filtered varieties partly in the expectation that they were safer. Some filters contained asbestos, or loose fibres that were inhaled into the lungs, which certainly added nothing to their safety. The second major innovation was the measurement and publication on packs of tar and nicotine levels. Many smokers switched to “light” or “mild” variants expecting they were safer. Again this has proved to be a chimera, since smokers typically smoke such variants harder to extract the maximum levels of nicotine from them.
Two papers in this collection explore the questions around making products safer. Bill King examines the prospects for safer products being produced by the tobacco companies. Ellerman and Borland consider the ways in which moves to safer products might be forced on the manufacturers through making tobacco a controlled substance.
Smoking rates continue to decline slowly in Australia. The most recent national survey4put daily smoking prevalence at 19.5%, with a further 3.6% less frequent smokers. In the absence of major new campaigns since then, it is unlikely that this figure has dropped substantially. What does seem to be happening, as Miller explores in her paper in this issue, is that the discrepancy between the affluent and well-educated groups and those who are poor and less-educated are widening. In this way, smoking is increasingly a key factor in explaining and reducing health inequalities in Australia. The smoking rates amongst Indigenous Australians are also very high – over 50% in many communities. The group with the highest rates is probably people living with mental illness where rates are around 75%. Again, the high smoking rates are a major factor in the reduced life span of Indigenous people and those living with mental illness.
Although not new, nicotine replacement products (NRT) continue to help many smokers to quit, especially if combined with behavioural counselling and social support. NRT is now available in four forms – gum, patch, inhaler and tablet. Tablets are the most recent innovation and it is possible that more formulations may come on to the market in the future. Another significant change is that NRT products are now available for open sale rather than being scheduled for supply in pharmacies only. Whether supermarkets and other retailers will choose to stock them and the consequent increase in accessibility and possible misuse remains to be seen.
Bupropion (Zyban SR (R) ), the only other pharmacotherapy sold for smoking cessation, had substantial uptake when introduced to the Australian market in 2001, especially after it became available on the Pharmaceutical Benefits Scheme. Such high uptake is a clear indication that many smokers want to quit, but need extra assistance to do so. Being available only by prescription brought GPs back to playing an important role in smoking cessation. Prescribing guidelines have recently been changed to require a return visit to the prescribing doctor in mid-course. This is likely to make usage more effective if doctors are able to provide encouragement and deal with any problems as they arise, as well as reducing wastage.
New clinical guidelines for GPs to use effective brief intervention techniques for smokers as part of the standard operating procedure for GPs were launched in June 2004. These guidelines are described in this issue by Suzie Stillman as is their usage for special groups such as smokers with a mental illness. The guidelines further extend the role of GPs as central in smoking cessation.
Although the knowledge that active smoking can cause illness and death can be said to be five decades old, the research on passive smoking is more recent, dating mostly from the 1980s. Nevertheless, the awareness that the smoke of others can harm family members, children, co-workers and fellow citizens has had a major impact on public policy. Smoking is often defended as an issue of personal choice where victims bring misfortune on themselves, but the same cannot be said of passive smoking. Hence passive smoking has galvanised the non-smoking majority to demand their right to clean air in public settings and workplaces.
The extent of harm caused by passive smoking is still subject to some dispute. Ridolfo and Stevensen5 estimated an annual toll of 128, compared to the annual deaths from active smoking of 18,891. Their passive smoking mortality estimate is based on exposure only in domestic settings and it is clear that it is a substantial underestimate. Roder6 estimates a more accurate figure is of the same order as the road toll – 165 per annum for SA, which would extrapolate to around 2000 nationally. Repace7, in a special report commissioned for The Cancer Council New South Wales, estimated the annual toll for non-smoking NSW club and bar workers to be 59 per year.
Despite this uncertainty, governments have begun to take action. Smoking is not permitted in workplaces in legislation for most states, with exceptions for hotels and gambling venues (except in Victoria). All workers need to be protected and action is underway to deal with this anomaly. SA and the ACT have announced firm timetables for comprehensive smoke-free workplace and public place regimes and the issue is under active consideration in several other states. Some local government authorities have broken new ground by making playgrounds for children and even beaches smoke-free, issues explored by Todd Harper and Jane Martin in their paper, A Smoke-free Australia – But When?
Jonathan Liberman examines the issues around litigation against the tobacco companies in Australia. Litigation has been a powerful mechanism for change in tobacco control and may yet be the mechanism for triggering the end of the tobacco epidemic. In Australia, the action brought by the late Rolah McCabe for compensation for her lung cancer against British American Tobacco (BAT) raised awareness of the actions of big tobacco to defend any litigation by fair means or foul. Although the case was initially successful in the Victorian Supreme Court, as a result of evidence presented that thousands of documents known to exist had been destroyed as part of BAT’s “document retention” policy, the case was appealed and is now before the High Court. The McCabe family face crippling costs being awarded against them if the action fails.
The enormous costs and possible risks for individuals bringing action is a major obstacle to litigation in this country. This is why the failure of the Australian Competition and Consumer Commission (ACCC), the body established to act as a watchdog for consumer interests, to fully investigate allegations of misleading and deceptive conduct by big tobacco in Australia is especially disappointing. Although this inaction is the subject of an investigation by a Senate committee, the ACCC has in addition stated that it does not have the resources to undertake a full investigation at present.
A Private Members Bill, initially sponsored by Mal Washer (Liberal) and Duncan Kerr (Labor), in the Commonwealth Parliament raised the controversial issue of the influence of the tobacco industry on political decision making. The Bill aimed to prevent tobacco industry donations through outlawing public funding of parties that accepted tobacco industry largesse. Although the Bill is unlikely to progress in Parliament, ALP leader Mark Latham has announced that his party will in future reject any donations from tobacco sources. The Prime Minister conspicuously refused a challenge to follow suit.
More recently it has emerged that the former chief-of-staff of the Prime Minister has been employed as a lobbyist by a tobacco company on the issue of tobacco pack warnings. Such is the power and the politics of tobacco control in Australia.
This issue of Cancer Forum summarises only some of the burning issues in tobacco control. Read on for more information and perhaps inspiration to take action in your own way to help end this major health disaster.
1. US Department of Health and Human Services. Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service. Washington: US Department of Health Education and Welfare; 1964.
6. Roder D. Approximate numbers of deaths, hospital separations and occupied hospital bed days per annum attributed to environmental tobacco smoke in South Australians aged 15 years and over. Adelaide: The Cancer Council South Australia; 2003.