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WE have known since 1950 that smoking is lethal, we know the vector (the global tobacco industry), and we have known for more than 40 years about the key measures needed to reduce smoking. Yet, smoking in Australia still causes some 19 000 deaths each year, and is likely to kill two-thirds of regular smokers.
Despite fierce opposition from the tobacco industry and its allies, there have been stunning declines over time in smoking among both adults and children, there are now significant declines in smoking in Aboriginal and Torres Strait Islander peoples and other vulnerable groups, and Australia is rightly seen as a world leader in action to reduce smoking. As the Prime Minister acknowledged in 2016, tobacco control is “one of [our] big public health successes”.
Globally and locally, the tobacco industry was under pressure during the first part of this century. There was universal acceptance of the evidence. The WHO Framework Convention on Tobacco Control was ratified by 180 countries. The industry’s reputation sank so low that some companies specified this as a risk in terms of their capacity to attract good staff. Even desperate and dishonest lobbying failed to prevent the measures they feared most, such as tax increases, strong media campaigns and plain packaging. A UK High Court judgement (one of many that have gone against tobacco companies) ruled that “The tobacco industry … facilitates and furthers, quite deliberately, a health epidemic”. Major companies in the United States were required to run advertisements confirming that they deliberately deceived the public about their products and the harms of smoking.
But these massive global corporations do not sleep: they have been strategising and are resurgent. Their opposition to measures that work is harder-line; their lobbying and use of front groups has increased; their resistance has extended even to litigation against governments, universities and the charitable sector, successfully delaying action in many countries; they have developed innovative approaches to maintain and increase sales of their “core product”; they are succeeding in rolling back tobacco control measures in some countries; they present themselves as health experts; they are making their products more attractive to young people; and they have developed new forms of promotion that distract from the action they fear.
While the companies have launched charm offensives in high income countries, they are also ruthlessly targeting low income countries, where there is immense cause for concern about the rising toll of deaths caused by smoking — estimated globally at more than 7 million each year.
Meanwhile, back in Australia, the steady decline in smoking that we saw until 2013, boosted by both plain packaging and the media coverage that surrounded this measure, along with regular tax increases, may have slowed between 2013 (12.8%) and 2016 (12.2%).
That should not be surprising after the larger-than-usual decline between 2010 and 2013 and absence of support for further action by governments. Indeed, occasional slowing in the decline is not a new phenomenon, as we saw in the 1990s, even after bans on tobacco advertising and promotion. We needed further evidence-based activity to maintain the momentum — especially major, hard-hitting media campaigns. The National Tobacco Campaign started in mid-1997, overseen by experts; there was more active campaigning; and we saw a return to encouraging declines.
No single initiative of itself will drive rates of smoking down in perpetuity. Each new measure magnifies the effects of what has gone before, but only if action is continually reinforced and properly resourced.
We should have reinforced and capitalised on the early impact of plain packaging and reinforced the impacts of tax increases. But five key factors have prevented this.
First, crucially and inexplicably, there have been no national media campaigns since 2012. The federal government gets more than $11 billion a year in revenue from tobacco taxes. Spending $40 million on media campaigns would be less than 0.4% of this. In an area where Australia led the world for so long, we have joined the back-markers.
Second, tobacco companies have maintained their long history of circumventing advertising restrictions and finding new ways to attract younger smokers. We have seen a plethora of product innovations (thanks to regulatory loopholes promoted even at point of sale), promotion of roll-your-own products (wrongly believed by many smokers to be less harmful than standard cigarettes), price discounting, brand names implying less harm, menthol flavours and youth-friendly filter gimmicks such as “Crushballs”.
Third, despite clear evidence in areas such as filter ventilation and menthol flavouring, there has been no action to regulate the product in ways that could significantly reduce both the harms and the attractiveness of the product. Even the Trump administration is currently considering approaches such as mandatory reduction of nicotine, an approach that merits further consideration elsewhere.
Fourth, there have been no curbs on tobacco industry efforts to influence public policy. Although Article 5.3 of the WHO’s Framework Convention on Tobacco Control, to which Australia is a signatory, prohibits any involvement by the industry in public health policy, tobacco lobbyists abound in Canberra and elsewhere, and at least two political parties are still willing to accept tobacco industry donations.
And fifth, the absence of evidence-based measures has allowed distractions to flourish.
E-cigarettes have been heavily promoted by tobacco companies, e-cigarette sales groups, some researchers and enthusiasts, vapers and assorted others. They are still in their early years, but the most authoritative report (from the US National Academies of Sciences, Engineering and Medicine) recently concluded that the evidence for cessation benefits is “limited”, the evidence for concern in relation to their impact on young people is “substantial”, and there is a need for more research on longer term harms.
There is nothing new in promotion of miracle cessation approaches, let alone new tobacco industry products that enable the companies to seek a role in health discourse and policy. Yet, for the past few years, promotion of e-cigarettes has been front and centre in media coverage on tobacco, supported by some with undoubtedly genuine concern for the health of smokers, but also by organisations and individuals who have previously supported tobacco industry lobbying, opposed action that runs counter to the industry’s interests or simply been absent from campaigns to reduce smoking.
The major tobacco companies have launched global and national promotional campaigns on these and other novel products. That is hardly surprising. As an independent investment analyst recently noted, they have a problem with “receding cigarette consumption stemming from strict government regulations and rising consumer awareness regarding the harmful impacts of tobacco”, and these new products are one means of “combating such challenges”. Indeed, the Philip Morris International company has reported dramatically lower sales and profits from its core product. What could be more in the company’s interests than opposing effective action while fostering distractions that may even help to promote smoking?
Tobacco companies have long sought to use alternative products as a means of renormalising their industry. Lights and milds, low tar and the tar derby, tobacco substitutes … the list is almost endless. Now around the world, we have countless e-cigarette brands, including the alarmingly attractive and student-friendly JUUL devices, and heat-not-burn tobacco products including iQOS, Ploom, Glo and assorted others, with thousands of flavours and other variants — all recklessly marketed ahead of good evidence on their longer term health and other consequences, all promoted in ways that are likely to attract the attention of young people.
Add to this the difficulty faced by those who support a precautionary position – a flood of personalised abuse, often vitriolic, that intimidates many from commenting in the public arena. This is a completely new phenomenon in tobacco control, compounded by bloggers, tweeters and others for whom abuse seems to be standard practice. There are legitimate debates to be had among people of goodwill, but not with the abusers and those who encourage them.
The Health Minister Greg Hunt deserves praise for standing up to tobacco industry and other lobbying on e-cigarettes, relying on advice from health authorities such as the National Health and Medical Research Council and the Therapeutic Goods Administration and protecting Australia’s well recognised product safety systems, and also for supporting action to address smoking in Indigenous populations.
But action over the past 6 years has stalled, at a time when it should have accelerated. In the absence of robust, well-funded national media campaigns and other action, reports about e-cigarettes have dominated the media as well as the time of the very modest numbers working towards evidence-based action on smoking. At the Parliamentary level, there have been two major inquiries (one Senate, one House of Representatives) on e-cigarettes: both concluded that the government’s approach and the status quo were appropriate; but both were enormously time-consuming. The companies may have failed to get their products on the market, but the focus on e-cigarettes has brought them substantial benefit as a distraction from effective action.
For those who worked long and hard to make Australia a world leader in tobacco control, it is deeply disappointing that political complacency in recent years has both led to lack of action and allowed distractions to dominate the public and policy arenas.
It is time to get back to basics.
The Government should now restore Australia’s global leadership by implementing the measures we know will be effective:
- Reduce smoking: use the forthcoming Budget to revive and maintain — with adequate funding —the hard-hitting national tobacco media campaign, complemented by health system encouragement and support for those seeking to quit. Failure to do so will please nobody other than the tobacco industry and its sympathisers;
- Reduce the harms: regulate products currently on the market, initially through banning menthol flavouring and filter gimmicks;
- Reduce tobacco industry capacity to undermine by ending all forms of tobacco promotion, including lobbying and public relations;
- Reduce exposure: support states and territories to take complementary action, including extension of smoke-free areas and effective measures to prevent sales to minors.
This is, after all, an epidemic that will cause the death of 1.8 million Australians. The 8 May federal Budget is the opportunity to get back on track, restore Australia’s global leadership, and save thousands more lives.
Professor Mike Daube, AO, is professor of Health Policy at Curtin University.
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Australia has been successful in reducing smoking between the 1970’s and around 2013. Between 2013 and 2016 the number of smokers actually increased at a time of plain packaging and record high taxes. Doing more of the same is not going to be enough. Countries where vaping and other forms of non combustable nicotine are available are seeing significant drops in smoking rates. The next step for Australia(legalising vaping) is apparent – to all except the who refuse to see.
Mike Daube advocates ‘getting back to basics’.
I’d suggest that the basics DO work in terms of low hanging fruit.
BUT, the resistant smokers by virtue of not being able or not being willing to quit are the high hanging fruit that the ‘back to basics’ are bloody well useless. Nicotine and the act of inhaling and exhaling smoke and/or vapour is very pleasurable for many.
Some in tobacco control have said ‘they’ll die off eventually’, it’s the kids we need to be concerned about. Most in tobacco control haven’t said it out loud but they believe it.
Vaping comes along and it looks like smoking so their visceral response is NO, NO WAY, NEVER ON MY WATCH.
Basically they don’t care about smokers, in fact they hate them.
They should be ashamed of themselves.
I’m not a fan of Big Tobacco, I know the damage from sustained inhalation of a substance directly into the lungs can do. But I am not an opposer, either. I like smoking. Infrequently. Nicotine is a wonderful medicinal adjunct. Patches, chewing tobacco, and similar chewing gums may provide the necessary dose as an effective mechanism in reducing a dependence, but do nothing for the sophisticated art of enjoying the ‘habit’. Far less gains in social cohesiveness.
Often I am buoyed from marvellously wafting tendrils of smoke invading my space. Instantly my senses are aroused and a hunger befalls me like a lion stalking nearby prey. I can smell it, I can taste it, I can feel it between my lips. It is a simply wonderful sensation. But, sadly, my pockets are devoid and there are none to be had. Though I loathe the after-taste, and the dank ashtray stench in my clothing, hair, and furniture, I crave the long, rolled leafy slenderness of a fine quality. Neither do I like the heavyness in my chest and slight cough a few days later.
I’ve grown more effective in controlling these visceral desires and have reduced my uptake from infrequently to rarely. May be once every two months, instead of every month. Perhaps I am one of the lucky few who can control an addiction, of sorts.
But tobacco is an industry like any other. And thus, We, in our industry, need to know how to deal with those who cannot for whatever reason control their own habitual regimen, instead of deciding not to treat them solely on the grounds that they were/are smokers (I know several anaesthesiologists who point blank refuse to administer anaesthetic to a smoker patient for an unrelated surgical procedure). Astonishing isn’t it. Such treasonous behaviour should be dealt with with disbarment.
Amusingly, when reformed long term smokers present to me and ask for some miraculous form of treatment that will transform their current COAD status back to something resembling that of a fresh twenty-year olds healthy lung capacity, explain: “Doc, the kids are off my hands, the wife has gone (presumably through divorce, or similar marriage nullifying renovation) and I’ve met someone else. We want to do things, start afresh. But, my chest feels heavy after a ten minute jog. What have you got for me?”
“Time”, is usually my initial response to that question. And when you observe the cogs of comprehension free-wheel short of understanding, the words ‘second-opinion’ illuminate on their foreheads.
When the right moment presents, I enquire as to whether they enjoyed their smoking, and for so long? Less than 1% say: “Yes. I enjoyed every one of them”. The others complain about not being able to stop when they wanted to. I estimate about 75% of the latter could have and chose not to, whilst the remainder had a serious dependency. Of those that enjoyed smoking, most could have stopped when when they chose to and often did. But they missed it so much, they purchased more – regardless of the price hikes.
My message is this: If you like it, do it sparingly. If you are dependent upon it and do not wish to continue and find difficult to cease, then seek medical assistance.
Government assisted prohibition is just wrong. So, too, are hideous packaging regimes with desperate depictions of morbidity agents used instead of brand names are nothing more than undergraduate reactionism; further, socialistic propaganda for what we can and cannot do here in Australia.
Dear Mike, imagine you meet a vaper who tells you he has quit smoking cigarettes thanks to e-cigs. What do you tell him/her? What do yo usay to the thousands people who shared the same experience?
Thank you
It is good to limit damage from smoking.
However, to be fair, the message is not all bad. And for that reason alone, a little less zealotry is recommended.
Nicotine has some interesting properties – it perks people up when they are down and calms them when they are anxious. Smoking is beneficial for some persons with inflammatory conditions – ulcerative colitis comes to mind. Cancer rates in smokers are high in our country but not high in Japan. This is not genetic because cancer rates are high in Japanese living outside of Japan.
For reasons like these I suggest what is needed is more education, more choice and less zealotry from governments and public servants. We dont need to be global leaders in the field of government dictates. Who knows why smoking is more benign in Japanese. It could be interesting to research. Possibly a cup of green tea with every two cigarettes will be the trick.
Prof Daube, whilst I applaud your tireless activity in this important area, I find myself in a quandary as to the prohibitionist stance you and other public health academics have taken with e-cigarettes, in an apparent evidence-free zone. I am no fan of big tobacco or their underhanded tactics to sell more product and hook more users, but as a clinician I take a pragmatic approach to harm reduction, when it is available. I am constantly reminded by the significant number of recalcitrant smokers I see outside hospitals every day (often parked in front of ‘no smoking’ signs), that not one solution fits all and that for some people the range of cessation & reduction methods currently available in Australia do not work for them.
I am also often asked whether e-cigarettes are better for health than combustible cigarettes, or whether they can help in cessation. I answer honestly – that I have not come across sufficient evidence to make a call one way or the other, that nicotine replacement is a proven and effective method for reduction, that can get you on the pathway to cessation, and that no matter what the delivery method, inhaling unknown substances into your lungs, including nicotine, can cause acute irritation and long-term harm to your health, including premature death.
Having just read your article and scanned the citations I am disappointed at the cherry-picked, misrepresentation you make about the Jan 2018 US Consensus Study Report on Public Health Consequences of E-Cigarettes. Quoted verbatim below is the first paragraph of the conclusion from the ‘Highlights’ page:
“Although e-cigarettes are not without risk, compared to combustible tobacco cigarettes they contain fewer toxicants; can deliver nicotine in a similar manner; show significantly less biological activity in most, but not all, in vitro, animal, and human systems; and might be useful as a cessation aid in smokers who use e-cigarettes exclusively. However, young people who begin with e-cigarettes are more likely to transition to combustible cigarette use and become smokers who are at risk to suffer the known health burdens of combustible tobacco cigarettes. The net public health outcome of e-cigarette use depends on the balance between positive and negative consequences.”
In medicine, we are able to deal with seemingly contradictory recommendations, made clear by qualification such as on age or usage, as in the conclusion above. We can advocate for harm reduction in other drug usage for those with addictions or that are just going to use anyway (e.g. shooting galleries, needle exchange, recent free pill testing at a music festival in ACT). Therefore, why is it not possible to seek further evidence on e-cigarettes for use in harm reduction and cessation in established adult users, whilst still conveying a clear message that these devices will more likely be a gateway to nicotine addiction, combustible cigarette use and all of its health consequences in current non-users (including the young)?
Also, if regulated appropriately, they could be as useful an adjunct as nicotine patches or gum (something that non-smoking youth are not breaking down doors to get access to). Allowing them into a regulated framework at least allows some control of the device parameters and ingredients. Currently, they may be illegal on paper but go largely unpoliced. If they are harmful, then they have more potential for harm outside of an established regulatory framework for registered, adult smokers.
Lastly, the success you and others have enjoyed on smoking rates in Australia has largely come from having a robust evidence base with which to come up with recommendations. An evangelical, prohibitionist stance about e-cigarettes is at a minimum disingenuous and at its worst potentially exacerbating harm to those you seek to help. As an academic, your duty should be to get back to the tenets of evidence in this debate. It is okay to debunk clever marketing from big tobacco about these devices when there is clear evidence to the contrary, or no evidence for their claims. However, it is also your duty to be honest and say we don’t know, when the evidence is not there yet. The debate on climate change was muddied by an evangelical, rigid, religious-like stance, that makes it so hard for the clear scientific evidence to strike the message it should today. End result is no action and much more harm done. Please don’t let the e-cigarette regulation debate go the same way.
The road of medicine is paved with good intentions, but has been littered with unintended harms when we don’t wait for, ignore or go against the evidence. Isn’t it time to swing this debate back to the evidence, including honesty about its absence, and the need to fund clearly defined studies to pursue evidence of the harm and/or utility of these devices?