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COVID-19 was first identified in December 2019 and declared a pandemic by the World Health Organization in March 2020. Australia is now seen as a world leader in taking action based on public health advice. This has entailed profound restrictions on social and economic activity, adverse impacts on many industries, and massive expenditure by government, resulting in extensive population-level behaviour changes, with strong community support. Our governments deserve praise for their early and effective action, as do many others, from health professionals to the wider community which has adhered so well to the restrictions.
There is another pandemic, stealthier and even more lethal, that we have known about for exactly 70 years. It causes 8 million deaths a year globally, 20 000 in Australia. We know the cause, the harms, the vector and the comprehensive public health approach recommended to bring it to an end. But tobacco, unlike COVID-19, is knowingly generated, promoted and sold by an industry with a history of lies, deceit and aggressive opposition to action that reduces the death, disease, misery and economic costs its products cause.
The two articles that first clearly identified smoking as a cause of lung cancer were both published in 1950 – Wynder and Graham’s Tobacco smoking as a possible etiologic factor in bronchiogenic carcinoma – a study of 684 proved cases, in JAMA on 27 May 1950, followed by Doll and Hill’s BMJ article, Smoking and carcinoma of the lung, on 30 September 1950. The years since have seen countless further reports confirming smoking and passive smoking as the causes of an extraordinary range of diseases. Fifty years ago, on 15 May 1970, the World Health Assembly passed its first resolution calling for action on smoking. For over 40 years, authoritative reports have recommended a comprehensive approach to combat this epidemic, with the same broad themes of public education, regulation, taxation and cessation support.
So how does Australia measure up, 70 years on?
Governmental action initially entailed little more than posters and leaflets. The first television advertisements about smoking, generated in 1971 by the pioneering Director of the Cancer Council Victoria, Dr Nigel Gray, were initially rejected by television stations. Substantial government media campaigns started in the 1980s, albeit at levels well below those for commercial products. The introduction of protective regulatory measures around the nation has been hard-fought against fierce opposition from the tobacco lobby. The Australian Government is a signatory to the WHO Framework Convention on Tobacco Control, including Article 5.3, specifying that tobacco companies should play no role in public health policy. The current federal Minister for Health, Greg Hunt deserves great credit for maintaining strong governmental resistance to relentless tobacco industry lobbying. He and his state and territory counterparts have also insisted on a strong, evidence-based approach to the regulation of e-cigarettes, with a special focus on protecting children and young people from the products and promotions that have caused much concern in the US and elsewhere.
After World War II, almost three-quarters of adult males were smokers, and smoking was increasing among females. The latest national surveys show 12% of adults as regular daily smokers (with further encouraging reports from some jurisdictions), and regular smoking among school students fell from 24% in 1984 to 5% in 2017 (3% in children aged 12–15 years). After plain packaging was implemented, the Imperial Brands company reported dolefully that “Australia is the darkest market in the world”. A recent study in Lung Cancer shows that if present trends in Australia continue, between 2016 and the end of the century, 1.9 million premature deaths will have been averted from lung cancer alone. Australia is widely recognised as a global leader, from advocacy to action, and from research to implementation.
But smoking remains a national catastrophe — our largest preventable cause of death and disease. Two in every three deaths among smokers can be attributed to smoking. Disadvantaged groups suffer disproportionately – Indigenous people, people with mental health problems and people with lower levels of education. Further, our successes in reducing smoking and achieving measures such as plain packaging and increases in the cost of cigarettes have led to unwarranted complacency. The reinforcing action that we needed has not occurred; we have good strategies, but little immediate action; and despite overwhelming evidence supporting well funded public education (and tobacco tax revenue of $17 billion p.a.), the last national media campaign was in 2012.
Now, more than ever, we have clear evidence about exactly what is needed to end the tobacco epidemic. Business as usual will result in some 20 000 tobacco deaths annually for decades ahead. Seventy years on from the certainty that smoking kills, this is unacceptable. The time is long overdue for Australian governments to plan an end to this preventable pandemic.
While there is rightly much planning about COVID-19 exit strategies, we must also plan for a tobacco exit strategy. There is now serious discussion internationally about the agenda for an end point – a target date for phasing out tobacco sales (here, here and here). This will require an agreed national strategy with a realistic date after which cigarettes and other tobacco products are no longer sold as standard commercial products. Importantly, this is not a strategy for banning smoking, but for phasing out commercial sales of tobacco products.
The strategy should comprise public education, regulation, and cessation support, with additional support for disadvantaged groups that suffer disproportionately from the health and economic harms caused by smoking and appropriate means of access for those remaining adults who are unable to quit. Nothing in this strategy would approach the constraints that have been so well accepted in relation to COVID-19.
In the COVID-19 context, WHO and other health authorities have emphasised evidence on the importance of smoking as an avoidable risk factor for COVID-19 and a poorer prognosis for smokers who are hospitalised as yet another incentive for smokers to quit (here, here, here, here and here). Early evidence from the United Kingdom suggests that more than 300 000 smokers there may have quit because of COVID-19 concerns.
Ironically, tobacco companies have sought to use the COVID-19 pandemic to promote their image through means such as philanthropy, and even to assert their concerns for health protection. The Philip Morris company closed a facility in Italy temporarily to protect its employees “out of an abundance of caution”, phrasing also used by Altria Tobacco. Sadly, the “abundance of caution” does not prevent these and other companies from selling and promoting products they have known are lethal for 70 years.
Moves to phase out tobacco sales will generate well funded and aggressive opposition from the tobacco companies that operate in Australia (albeit based overseas). Their concern will be twofold: first, the loss of a lucrative market; second, an awareness that, as with plain packaging, once approaches previously considered impossible have been successfully introduced in one country, others will follow, including in low and middle income countries, where their annual market growth is some 20 times greater than in high income countries. But even despite the industry’s lobbying, there is widespread awareness that, as summarised by a 2016 British Supreme Court judgement, this industry “facilitates and furthers, quite deliberately, a health epidemic. And moreover, a health epidemic which imposes vast negative health and other costs”.
All those now selling cigarettes have long been aware that they are selling a lethal product. This further applies to all who support the operations of tobacco companies, including public relations agencies, lobbyists, lawyers, accountants and front groups. The Australian tobacco market is dominated by supermarket chains, but they and smaller outlets would have time to plan for the end of their tobacco business in the knowledge that people will still be able to spend – although on healthier products. There should also be scope to provide corner stores with some support for transition from the government’s tobacco revenues. Treasury would have to plan for an end to those revenues, but also for an end to the much greater social and economic costs that smoking engenders.
Within weeks of evidence demonstrating cause for concern, Australian governments responded strongly to the COVID-19 pandemic, acting on the basis of public health recommendations. This will have prevented thousands of deaths. Just as we need to get to the other side of the COVID-19 pandemic, after 70 years, we also need to get to the other side of the tobacco pandemic. We have made great progress in reducing smoking, but we need a new sense of urgency. Even now, the tobacco giants are running global public relations and lobbying campaigns seeking to circumvent the WHO Framework, and to present themselves as responsible, even health-focused companies. Meanwhile, we daily see further examples of the ways they seek to counter and chill public health action, market their products to young people and vulnerable populations, attack and undermine health organisations and experts, and ensure further increases to the global tobacco death toll.
World No Tobacco Day is on 31 May 2020. Seventy years on from Wynder and Graham and Doll and Hill, Australian governments have shown over the years that determined governments working with well organised health coalitions can take on and beat Big Tobacco. They are currently seeing the substantial health benefits that accrue from relying on public health advice in response to a global pandemic without a commercial vector. Now they can show the world that a tobacco exit strategy is feasible. They should develop a plan to phase out the commercial sale of tobacco products in Australia by 2030.
Emeritus Professor Mike Daube AO is with the Faculty of Health Sciences at Curtin University.
Professor Rob Moodie is currently Deputy Head of School and Professor of Public Health at the University of Melbourne’s School of Population and Global Health (MSPGH), and Professor of Public Health at the College of Medicine, University of Malawi.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Thank you for a sensible commentary on the end game. I sincerely hope that Australia will head down the path to phasing out sales of tobacco. If it were a referendum tomorrow it would pass given the low support for smoking in the community. It seems incongruous that the only country where this was seriously considered was Singapore which was able to ban chewing gum on the basis of the litter problem it caused. One has to wonder if political will is weak because industry interference is high! And it won’t just be the tobacco industry – it will be all other businesses that are commercial determinants of health who will pay money to fight regulation. We need a master plan! Thanks for raising the debate.
The huge economic costs of COVID-19 will be borne by many generations to come so it makes sense to use the tobacco pandemic to pay for future pandemics. How? By raising tobacco taxes to reduce consumption and raise revenue to offset both the health and economic costs of COVID and future pandemics.
Banning the sale of tobacco is a nonsense.
This suggestion ignores the example of Prohibition in the USA and our recent experience with illicit drugs.
Controlling and limiting sales through legislation and taxation has been very effective in harm minimisation.
We will only ever be able to minimise harm not eliminate the effect of tobacco as it is highly addictive.
Australia led the world in plain packaging of cigarettes and countries all over the globe followed. Could Australia be the leader in phasing out sales of the single most deadly consumer product in history? It’s an exciting thought. Research shows that reducing easy availability of products does reduce use and makes it easier for people to get free of their addiction, and 70% or more of smokers say they want to quit. The world will be watching to see which countries finally bring an end to the most destructive pandemic caused by an industry.
This is a bold and sensible plan. to phase out tobacco sales by 2030.
We have been advocating similar approaches for many years through the Tobacco Free Generation and the T21 proposals. However, this is a more direct and simple approach.
Smoking kills 560 Tasmanians, alcohol about 114, traffic deaths about 35 every year, and COVID has killed 13 so far.
We have written articles published in international journals highlighting the dangers of COVID-19 to smokers and those with smoke damaged lungs. However, the Australian media has remained disinterested.
The tobacco pandemic has been forgotten because those who profit from selling this lethal product have slithered in to the minds and social circles of politicians. Not corruption, but certainly crony capitalism. Article 5.3 of the FCTC has not deterred them, or stood in their way.
If we cannot afford thousands of COVID deaths, then we cannot afford thousands of tobacco deaths.
We need to free up our hospitals, improve the health of disadvantaged communities and rural locations like Tasmania – where we have one suburb with a 40% smoking rate.
Excellent discussion that we need to bring into the public domain.
There’s another stealthy pandemic that kills 7 million people every year: air pollution. https://www.who.int/westernpacific/health-topics/air-pollution
Here too we find highly profitable yet dangerous products, a billion $ industry influencing policy makers, obscuring evidence and delaying the inevitable move away from an outdated, dangerous and expensive method of producing energy, heat and transport at the cost of human health and lives.
As in many other countries, smoking rates in Australia have been declining for decades. But since 2013, Australian smoking rates have been virtually flat despite vigorous tobacco control policies. Yet the decline in smoking rates has accelerated in UK & US where vaping nicotine is much more popular than in Australia where a de facto ban on vaping is imposed. Vaping is much less risky than smoking & a growing number of studies show it is the world’s most popular & most effective quit smoking aid. Vaping nicotine is a form of harm reduction, an approach to psychoactive drugs which is generally effective, safe & cost effective. Australia endorses harm reduction as part of our National Drug Strategy, National Tobacco Strategy and is a signatory to the 2003 Framework Convention on Tobacco Control which also endorses tobacco harm reduction. The aim of Australia’s tobacco policy should be to reduce smoking related cancers, heart and lung disease as fast as possible. Australia should make it easier for smokers to switch from high risk smoking to much lower risk vaping, snus or heated tobacco products. How absurd that nicotine in cigarettes is exempt from Australia’s Poisons Standard but nicotine for vaping is included!
In the past 5 years, the use of nicotine delivered through e-cigarettes has significantly increased among adolescents and young adults and this dangerous trend would reverse 7 decades of progress in the fight against nicotine addiction (1). Nicotine addiction is a pediatric disease (2) and nicotine exposure to the developing adolescent brain has been shown to have long-term cognitive and behavioral impairments (3).Juul uses nicotine salts in its vaping devices to deliver “dramatically higher levels” of nicotine to the brain with less irritation and “Adolescents simply do not stand a chance”(4). JUUL appears to be associated with the youth e-cigarette epidemic, attracting new users and facilitating frequent use with their highly addictive nicotine content and appealing flavors (5). The Surgeon General estimates that 5.6 million of today’s youth will die prematurely from a smoking related illness (6).
Systematic review and a meta-analysis published recently in the Journal PLOS ONE (https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0233147) confirms that the current smokers are at a higher risk of dying from COVID-19 than non-smokers. American Academy of Family Physicians recently developed guidance stating that “people who smoke or use vapes or e-cigarettes have a significantly higher risk of contracting respiratory infections like coronavirus. People with decreased lung function caused by smoking or vaping are more likely to develop serious complications caused by infections.”(7).
REFRENCES:
(1). Chadi N, Hadland SE, Harris SK. Understanding the implications of the “vaping epidemic” among adolescents and young adults: A call for action.Subst Abus. 2019;40(1):7-10. doi: 10.1080/08897077.2019.1580241.
(2). Kessler DA, Natanblut SL, Wilkenfeld JP, Lorraine CC, LindanMayl S, Bernstein IBG, Thompson L. Nicotine addiction: a pediatric disease. J Pediatr. 1997;130:518–524.
(3). Surgeon General’s report (2016) US Department of Health and Human Services. E-cigarette use among youth and young adults: A report of the Surgeon General-http://e-cigarettes.surgeongeneral.gov/documents/2016_SGR_Full_Report_non-508.pdf.
(4). The American Academy of Pediatrics- Congressional testimony 2019-https://www.cnbc.com/2019/10/15/pediatrician-to-congress-adolescents-dont-stand-a-chance-against-juul.html
(5). Vallone DM, Cuccia AF, Briggs J, Xiao H, Schillo BA, Hair EC.Electronic cigarette and JUULuse among adolescents and young adults. JAMA Pediatr. 2020 Jan 21. doi: 10.1001/jamapediatrics.2019.5436
(6). National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. The Health Consequences of Smoking-50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention (US); 2014
(7). NYSAFP clinical guidance to prevent tobacco and vaping use during Covid 19 pandemic-http://www.nysafp.org/News/What-s-New/COVID-19-Resources
Smoking remains a national catastrophe in spite of over 50 years of vigorous public health campaigns to eliminate it. Traditional tobacco control strategies have been effective but are now reaching a point of diminishing returns.
We would all love to see Big Tobacco magically disappear, but realistically we all know that is not going to happen.
What is our primary goal? To destroy Big Tobacco or to prevent death and illness from smoking. If it is the latter, we need all possible strategies to be on the table.
Smokers who can’t quit with conventional methods should have access to reduced risk alternatives such as vaping, snus and heated tobacco products.
Tobacco harm reduction is mandated by Australia’s signing of the FCTC and is one of the three pillars of The National Tobacco Strategy. However, it is supported in theory, not practice.
Tobacco harm reduction “has the potential to lead to one of the greatest public health breakthroughs in human history by fundamentally changing the forecast of a billion cigarette-caused deaths this century” https://bit.ly/36b9LTy
It is time to focus on the main purpose of public health, to save lives and improve health by whatever means works. It is time to add tobacco harm reduction to the existing strategies for an optimum outcome.
Let’s compare the youth use of a prohibited drug, cannabis, to tobacco (a regulated one) in:
Australia: “adolescents aged 14–19 years are now more likely to have ever tried cannabis (25.5%) than tobacco (16.2%).” https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/TR.289.pdf
USA: “marijuana use among high school students was more common than current cigarette use (23 percent compared to 18 percent).” https://www.cdc.gov/media/releases/2012/p0607_yrb_telebriefing.html
These figures seem to indicate that a policy of regulation may already be superior to a policy of prohibition.
Ending the commercial sale of cigarettes is an enormous concept which occurs at the difficult nexus of health, economics, and politics. It’s a concept that will take time to design, and time to implement. Sadly, time is also the neutral peddler of Big Tobacco’s agenda: new smokers and more sales. If 2030 is the goal, then it needs commitment ASAP. Health and economics are there – politics needs to step up.
Some of us do not “applaud the drastic tactics being used to fight COVID19”.
The necessary discussion to had before starting down this specific (i.e. tobacco) path is a broader one of how great should be the reach of the nanny state in our lives. Is it reasonable for doctors – in response to the current virus pandemic for example – to effectively imprison elderly pensioners away from their families for months ‘for their own good’?
The list of roles for the nanny-state will be long. Once we have dealt with tobacco, surely alcohol should be the next to be banned: not only for its direct health side effects but also for its role in domestic violence and road deaths. Yet medicos seem less enthusiastic in this pursuit: a few too many hobby vineyards and fine cellars perhaps?
Curious how they can always find some obscure study that supports the anti-oxidant benefits of a fine red…
Australia’s Health Minister Greg Hunt says tobacco causes over 20,000 Australian lives annually (with no mention of how many live with constant suffering and disability) as well as costing $137 billion each year. He announced last year that he would spend $25 million over a four year period to encourage Australia’s 2,500,000 smokers to quit.
This poison is available at nearly every corner shop, newsagent, supermarket (not Aldi), pub, club and petrol station. The big supermarkets even have the gall and hypocrisy to sell quitting products and to promote healthy eating and family values – whatever that is.
The so-called warning “SMOKING KILLS” is ignored – who (other than medical staff) has ever witnessed a person die from smoking? It’s no wonder that teenagers still start smoking, if only to defy public health and their parents’ warnings. Those same parents are often more concerned with illicit drugs, alcohol, driving, suicide and extreme sports.
Far worse -the toxins in second-hand tobacco smoke kill innocent bystanders – babies, children, frail-aged, workers. There is, according to all of Australia’s Health Ministers “no safe level of exposure to second-hand tobacco smoke”.
Smokers now have easy, affordable access to approved nicotine replacement products (patches, gum, lozenges and sprays) which don’t affect themselves nor others.Non-smokers have no alternatives – they must use nose and mouth to breathe.
Simon Chapman’s Smoker’s Licence concept has great merit – especially with financial incentive for some fees to be recouped on the decision to finally quit.
The TOBACCO pandemic has been tolerated and ignored for far too long. One simple reason could be that politicians and decision-makers live and work out–of-sight and out-of-smell of tobacco-smoking.
We applaud the drastic tactics being used to fight COVID19 – there’s no reason the same determination could not be used to bring this 70 year pandemic down.
• Consumer products found to be hazardous are regularly removed from the market, such as toys that present a choking hazard, airbags in cars, batches of contaminated foods, components of complex goods that work improperly e.g. mobile phones.
• Clearly, the bizarre exception to these health and safety standards is the cigarette, which has been shown to kill as many as two thirds of its long-time users.
• Cigarettes have continued to be sold even as evidence about the harms they cause continued to mount because of the political power of the tobacco industry. It’s time to start phasing out the sale of tobacco products.
Phasing out commercial sales of tobacco can be the ‘new normal’ way to protect people from a dangerous product. Horrendous death and suffering could have been prevented by early, decisive action when the threat was first identified but as Daube and Moodie propose, action by 2030 will protect millions in the future.
No other consumer product kills two in three users when used as intended. Massive off-shore companies make millions of dollars while killing their Australian customers, with their products available to purchase in more places than bread and milk. It’s past time to start phasing out the commercial sale of tobacco product while restoring measures that are proven to help people who smoke to quit and prevent kids to start smoking.
Studies repeatedly indicate that some 90% of smokers regret ever starting. 40% make a serious attempt at quitting each year. There is no other product where such loathing and disloyalty is so widespread among users. With 13.8% of Australian adult smoking daily, and 90% regretting it, only 1.4% of Australia adults smoke and don’t regret it. This tiny group’s preferences to continue smoking could be respected by a decision to make legal access to tobacco products dependent on a smokers license. Millions of Australians have temporary and sometimes continuing de facto licenses to use drugs which can benefit health. These are called prescriptions. In all but chaotic, impoverished nations where pharmaceutical drugs can easily be obtained without a prescription, the world thinks this is a totally sensible way of regulating access to them.
It is time we did this with tobacco products. I argued the case for doing this, including considering all the top-of-mind objections, in PLoS Med here https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001342 and in this 18m video here https://www.youtube.com/watch?v=wNfTBbTEgB8&list=UUhyxYzq0ZAB0iBw-A1l5jFA