Submission received from Margo Saunders on the draft for consultation of the National Tobacco Strategy 2012-2018
Draft for Consultation: National Tobacco Strategy 2012-2018Submission from: Margo Saunders
Public Health Policy Researcher/Writer*
(Senior Tobacco Policy Officer, ACT Health, 1992 – 2006)
1.Policy context:In order to avoid this Strategy appearing to be another ‘siloed’ approach, it needs to take account of, and explain how it will link to, other relevant strategies and policies including the National Women’s Health Policy, the National Male Health Strategy, the National Mental Health Strategy, the National Primary Health Care Strategy, and the National Chronic Disease Strategy, and policies and strategies relating to childhood and youth health and to the aged.
2. Smoking and the burden of disease:Given that smoking has been shown to cause harm to just about every organ in the body (For more information please visit Centers for Disease Control and Prevention website), the Strategy does not adequately explain the burden of disease represented by tobacco smoking. Specifically, smoking needs to be highlighted as a risk factor for a range of diseases and conditions, not only among the Indigenous population. It would also be helpful to draw attention to the fact that smoking has a synergistic effect with certain occupational exposures and with other activities (for example, with the consumption of alcohol), resulting in an increased risk of certain diseases and conditions.
3. Goals and objectives:De-normalising smoking needs to be given more prominence and acknowledged as an over-arching objective rather than being relegated to the last 3 words in the 7th and final objective.
4. Primary prevention:There needs to be a stronger emphasis on the importance of primary prevention – ie, on discouraging young people from starting to smoke. Studies have shown that long-term smokers who have quit still experience a significant decline in their quality of life in later years compared to never-smokers. (see: ‘The Effect of Smoking in Midlife on Health-Related Quality of Life in Old Age -- A 26-Year Prospective Study,’ For more information please visit The Jama Network website ) While encouraging quitting is a laudable public health goal, the most significant health benefits for Australians in the long term will be made in preventing uptake. Australia has had a National Tobacco Campaign focusing on smoking cessation; there is a need for a major social marketing effort designed to prevent smoking initiation and the progression from experimentation to regular smoking.
5. Priority populations:
- Targeted approaches are to be encouraged, but the targeting must be appropriate. There are population groups – not necessarily ‘disadvantaged’ – that should be given special attention. These are social and occupational groups with high levels of smoking, which may be characterised by low socio-economic position, as opposed to being financially disadvantaged. Examples of these groups include ‘pink collar’ workers; workers in the hospitality industry; males in the building/construction sector (who still stop for ‘smoko’); males and females in their 20s and 30s in casual and intermittent employment; single parents, including those in changing relationships and accommodation who rely on government benefits. Individuals in many of these groups report that their their social groupings are often made up predominantly of smokers, and the social norms around tobacco use appear to be relatively more pro-smoking for low socio-economic position at the personal, community and societal levels. These social norms need to be acknowledged in social marketing campaigns, policy initiatives and other interventions. (See: Paul et al., The social context of smoking: A qualitative study comparing smokers of high versus low socioeconomic position BMC Public Health 2010, 10:211, For more information please visit BioMedCentral website) Demand-reduction strategies should be developed and implemented for tertiary educational institutions and workplaces, especially within the service sector and manual trades.
- The Strategy makes no mention of tertiary students and young adults as a priority population group. Young adults have certainly been targeted by the tobacco industry, for several reasons: individuals age 18 or over are considered ‘fair game’; young adults attend social venues with a ‘pro-smoking’ environment; and young adults are seen as role models for adolescents. Many young people begin to smoke, or progress from occasional to regular smoking, at university or when they start work. Recent studies have shown disturbingly high levels of smoking among Australian university students, including prevalence of 24.9 per cent among male students and 16.6 per cent among female students (see: ‘Smoking in Australian university students and its association with socio-demographic factors, stress, health status, coping strategies, and attitude’, For more information please visit Griffith University website )
It should also be recognised that, among young adults and other groups of people who smoke, smoking should not be perceived as an independent health behaviour, as smoking is often one component of a cluster of unhealthy behaviours (see, for example: ‘Smoking, weight loss intention and obesity-promoting behaviors in college students,’ http://www.ncbi.nlm.nih.gov/pubmed/16943457; The clustering of health risk behaviours in a Western Australian adult population’, For more information please visit The National Center for Biotechnology Information website ;’ Clustering of health-related behaviors among 18-year-old Australians’, For more information please visit The National Center for Biotechnology Information website ; ‘Policy responses to multiple risk behaviours in adolescents’, For more information please visit Oxford Journals website).
- Indigenous health workers are another group whose smoking deserves special attention. Smoking among Indigenous health workers was identified as a concern in the early 1990s, and a significant proportion of these workers still smoke today. ‘Many health workers, before heading off to see Aboriginal people, stand around their four-wheel-drives "having a puff’ (For more information please visit Creative Spirits website ). Being a smoker has been shown to present practical obstacles to working effectively in their communities to promote non-smoking, as well as being a factor in health workers’ knowledge and understanding about tobacco. Indigenous health workers who smoke were far more likely than non-smokers or ex-smokers to believe that ‘smoking can’t be all that bad for you because many people smoke their whole lives and live to a ripe old age’ and to believe that ‘smoking in the home is unlikely to affect children’s health’ (‘Tobacco control practices among Aboriginal health professionals in Western Australia’, For more information please visit Curtin University website). Recent studies have concluded that assisting Indigenous health workers to quit smoking may provide an important opportunity to address high rates of smoking in Indigenous communities, and that further research is required to assess the most practical and effective quit support (‘A review of the barriers preventing Indigenous Health Workers delivering tobacco interventions to their communities,’ For more information please visit Wiley website).
6. Gender:There is a substantial literature on smoking and gender, as well as information about effective health communication with men and women. The Strategy needs to acknowledge the role of gender in relation to uptake and cessation as well as gender differences in relation to social marketing initiatives ( For more information please visit Canberra University website ).
7. Evidence in the form of qualitative research:The Strategy needs to place more emphasis on the role of ‘lay epidemiology,’ or qualitative research, in contributing to a sound basis for future initiatives. Social marketing and other initiatives intended to discourage uptake and encourage cessation need to be grounded in qualitative research and analysis which address the psycho-social factors which support and promote smoking, as well as the roles of social environments in which smoking occurs. It is essential that initiatives reflect an understanding of the way that smoking is perceived by smokers and potential smokers, of the emotional bonds that smokers feel with smoking, and of the influence of the social contexts in which smoking behaviour occurs. (There is an extensive literature on these issues. See, for example: ‘Factors associated with smoking cessation in a national sample of Australians,’ For more information please visit National Center for Biotechnology Information website ; ‘Heavy smokers: A qualitative analysis of attitudes and beliefs concerning cessation and continued smoking,’ Oxford Journals website ; ‘Eliciting the smoker's agenda: implications for policy and practice’, For more information please visit National Center for Biotechnology Information website ; and ‘Strategic communication and anti-smoking campaigns’, For more information please visit University of Technology Sydney website)
8. The lifecourse:It is surprising that the Strategy makes no mention of addressing smoking across the ‘lifecourse’. ‘Lifecourse’ approaches have been adopted in numerous health promotion and disease prevention programs and campaigns. The relevance of ‘lifecourse’ has featured in the literature on tobacco use -- eg, ‘While all the participants spoke of knowing about the health and social implications of smoking, there appeared to be ‘barriers’ to taking on board assessments of risk over the life course.’ (‘Eliciting the smoker's agenda: implications for policy and practice’, p.92: For more information please visit National Center for Biotechnology Information website ). Lifecourse approaches have been particularly utilised in relation to men’s health and have been adopted in initiatives which focus on the issues around smoking cessation for new or expectant fathers (see, for example, various publications by John Oliffe and Joan Bottorff at: The University of British Columbia website ).
9.Health literacy:It is surprising that the Strategy makes no mention of health literacy – the ability to access, interpret and apply information to health-related decisions. Many smokers are not aware of how smoking interacts with other risk factors to increase the risk, severity or complications of particular diseases and conditions. Research has also shown that there is still some degree of misinformation – for example, with a majority of both younger and older smokers believing that nicotine causes cancer (Personalized Care May Help Smokers Quit, For more information please visit Jama Network website).
10. Cessation:In relation to smoking cessation, as well as other key areas, the Strategy is big on the ‘what’ but very sketch on the ‘how’. Perhaps there is to be a separate implementation or action plan? Certainly more attention needs to be given to strategies for actually achieving the goals and objectives.
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In relation to cessation, there need to be links with primary care and the new Medicare Locals. There is scope to develop personalised smoking cessation strategies, including providing feedback on ‘lung age’ and evidence of how smoking, and quitting smoking, is affecting individuals’ health. Hospital patients who smoke are a key group for smoking-related care, as well as an important group for the collection and analysis of information about the level and type of care provided.
Smoking cessation research, both within Australia and internationally, is a lively area, with numerous findings about effective approaches to smoking cessation in primary care and other settings. Basic issues such as the role of NRT and pharmacological assistance in cessation (vs un-assisted quitting) continue to attract attention. There is also interest in the potential roles of social media and new technology to assist in smoking cessation, as well as interesting findings concerning the role of financial incentives for encouraging cessation.
Importantly, findings have shown that simply encouraging individuals to quit – and even subsidising the costs of nicotine patches and gum – will not be effective if the family and social contexts of smoking are ignored.
11. Acknowledgement of a continuum of approaches:The Strategy says nothing about a range of approaches which are being suggested within Australia and internationally, particularly those which focus on an ‘end-game’: the phasing out of tobacco smoking altogether. These approaches include proposals to continually reduce nicotine levels in tobacco products, thus reducing addiction, as well as proposals for smokers to be licensed in order to purchase tobacco. The Strategy probably needs to acknowledge the directions in which tobacco policy discussions are heading.
12. Information:Information on tobacco use needs to be more frequent and more useful. A lack of regular information on smoking in Australia makes it difficult to track the impact of various policies and programs and to base interventions on current trends. Australia needs a comprehensive annual survey which tracks tobacco use and other health risk (and protective) behaviours. We also need State and Territory-level tobacco sales data (and the reference in the Strategy to duty-free sales should be up-dated).
The failure to appreciate the relationships between smoking and other unhealthy behaviours, as noted previously, has been compounded by the siloed way that information (eg, findings from the Australian School Students Alcohol and Drug Survey and the National Drug Strategy Household Survey) are typically reported, where findings relating to each specific behaviour are reported independently from each other, with no ‘cross-tabs’ and therefore no ability to see which behaviours are ‘clustered’ and how these relate to characteristics of students. Although some information has been obtained over time about the characteristics of students who are most likely to become smokers, the clustering of risk behaviours provides important additional information about psycho-social factors and possible avenues for intervention.
13. The tobacco industry:The Strategy says virtually nothing about measures aimed at greater tobacco industry accountability for the harms caused by their products. These could include a levy on Australian tobacco company profits to help finance cessation and health promotion initiatives; a requirement that government superannuation funds not invest in tobacco companies; and an end to political donations in any form to Australian political parties or candidates by tobacco companies.
14. Tobacco use in all its forms:It is astonishing that this Strategy document includes no mention of hookahs, water pipes, or cigars. Water pipes have gained in popularity in recent years among certain groups, and the Strategy should acknowledge the various ways that tobacco is used and the harms associated with these methods.
15. Harm reduction:Although ‘harm reduction’ is mentioned in the Strategy, it is not really discussed. Consideration needs to be given to what approaches will be adopted for highly-dependent smokers who are not responsive to cessation efforts and for whom alternative nicotine delivery products may represent a less harmful option.
16. Governance, transparency and accountability:There are questions about whether the structures which form the decision-making framework for tobacco control are as appropriate as they might be in terms of drawing on relevant knowledge and expertise. Do groups such as the Standing Committee on Tobacco, which advises IGCD, and the Mental Health, Drug and Alcohol Principal Committee, which is responsible for overseeing the implementation of the National Drug Strategy, actually include appropriate expertise on tobacco issues? To what extent is the emphasis on law enforcement, especially to the exclusion of expertise in other areas, appropriate for high-level decision-making on tobacco control initiatives? The list of members of the Standing Committee on Tobacco should be publicly available (as it does not currently appear to be).
17. Specific actions proposed in the Strategy:Many of the specific actions proposed in the Strategy are worded in ways which are excessively guarded. They indicate that more time and money will be devoted to ‘considering’, ‘monitoring’, and ‘exploring’, when sufficient evidence either already exists or will only exist if an initiative is undertaken and assessed. The ‘soft’ approach taken in the present document – particularly in section 6.5 ‘Eliminate remaining advertising, promotion and sponsorship of tobacco products’ -- compares unfavourably to previous National Tobacco Strategies which made clear commitments to particular actions.
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Specific actions which should be included in the Strategy include:
6.5.4 Require (not, ‘Investigate the possible benefits of requiring’) tobacco companies to report regularly on expenditure on any form of tobacco promotion and marketing activity.
6.5.5 Eliminate (not ‘Explore regulatory options to eliminate’) any remaining forms of tobacco promotion including advertising of price specials, public relations activities,
payments and incentives to retailers and proprietors of hospitality venues.
6.5.6 Prohibit (not, ‘Consider and develop regulatory options to prohibit’) the remaining display of tobacco products at point of sale.
6.5.7 Eliminate the advertising and sale of tobacco products over the internet (not ‘Restrict the advertising of tobacco products on the internet by passing the Tobacco Advertising Prohibition Amendment Bill 2010’).
6.5.8 Develop options for restricting (not, ‘Explore the possible benefits of regulatory restrictions on’) incentive programs between tobacco manufacturers, wholesalers, and retailers.
6.5.9 Ensure that tobacco is removed from all (not, ‘Consider and develop regulatory options to remove tobacco from’) retailer shopper and reward schemes.
6.5.10 Adopt measures designed (not, ‘Consider and develop policies and regulatory options consistent with Article 5.3 of the FCTC) to prevent tobacco company interference in public health policies.
6.5.11 Implement measures to ensure that films classed for viewing by children do not include depictions of smoking that make smoking look desirable or normal, and such depictions should be reduced overall. GUIDELINES should be developed to ensure that Commonwealth, State and Territory film finance agencies do not provide financial support to films with positive depictions of smoking or other forms of tobacco use. (Not, ‘Continue to monitor the portrayal of smoking in movies and the adequacy of the current classification guidelines.’)
6.6.7 Ensure that all jurisdictions enact and implement effective (not, ‘Consider and explore regulatory options to implement’) tobacco licensing schemes for retailers and wholesalers. CONSIDER and explore options for a national licensing database.
6.6.8 Reduce the number of tobacco outlets (Not, ‘Commission research to examine the potential benefits, feasibility and best practice regulatory approaches of placing controls on the number and type of tobacco outlets in the community.’)
6.7.5 Ensure that all enclosed public places and workplaces are non-smoking, including all enclosed areas of casinos and other gaming establishments and areas (not, ‘Enforce existing smoke free legislation and work towards all workplaces being smoke free (including outdoor areas in restaurants and hotels,’) near the entrances to buildings and air conditioning intake points, and in workplace vehicles).
6.7.8 Develop appropriate measures to ensure that residents of multi-unit residential facilities are not subjected to tobacco smoke in their premises or in common areas (not, ‘Consider and develop options to reduce exposure of residents to smoke drift in multi unit developments.
6.8.7 Institute policies and programs which would institutionalise the treatment of tobacco dependence in Australia’s health care system, including those designed to ensure that (not, ‘Develop systems that encourage) health professionals [to] routinely ask patients about their smoking status and provide smokers with appropriate advice and support to quit.
18. Tobacco control stocktake:It would be helpful if the Strategy included a ‘stocktake’ against the previous National Tobacco Strategy in terms of what has been achieved.
Such a document would have been helpful at the consultation stage so that we could see, at a glance, whether, for example, all jurisdictions have enacted legislation for tobacco retail licensing, the prohibition of tobacco sales from vending machines, etc. Without this, it is difficult to say what remains to be done.
For example, it is not possible to tell whether the absence of a particular commitment – such as the commitment to end the sale of tobacco products from vending machines or from any other device which avoids a proof-of-age check -- is a substantive omission or is not included because it has already been achieved in all States and Territories.
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19. Other actions:An admirable blueprint for future action was provided in the National Preventative Task Force’s 2008 technical report, Tobacco Control in Australia. It, together with Task Force’s final report, Australia: The Healthiest Country by 2020, has done much to make the case for encouraging and supporting smoking cessation and for discouraging smoking initiation and halting the progression from experimental to regular smoking. Doing these things effectively will require an on-going, comprehensive, integrated and increasingly sophisticated set of strategies. I am not confident that the current Strategy document reflects a commitment to such strategies.
* I am an Affiliate Member of the Freemason’s Foundation Centre for Men’s Health (Adelaide) and a member of the Public Health Association of Australia and the Australian Health Promotion Association. The views presented in this submission are my personal views and should not be taken to represent the views of these organisations.
Page currency, Latest update: 14 March, 2013