Public Submission by Lung Health Alliance - Draft National Tobacco Strategy 2010 — 2018
National Tobacco Strategy 2012-2018
Submission by the Lung Health Alliance
25 June 2012
The Lung Health Alliance welcomes the incremental development of National Tobacco Policy (NTP) and the opportunity to review this draft policy. We have the following global comments and then some particular comments on each of the key policy aspects.
PriorityThe critical issue here is to remain truly committed to a 10% adult smoking target by 2018 and the described substantial smoking prevalence reductions in key groups. This is challenging but in our view achievable. From this commitment the quantum and nature of the policies and actions flow, as will a need to monitor progress in the period 2015-2016 to continue, alter or intensify actions to meet that target.
Actions to be implementedTo achieve, meet or exceed the reduction in smoking rates many or all of the specified actions for which there is evidence of efficacy will need to be implemented. Proven ineffective interventions will need to be ended. Whatever interest groups might be attached to these programs, they will have to be stared down.
It is also important that the NTP be part of a whole of Government approach so that policies and actions in relation to our primary mission, Lung Health, are fully compliant with it.
Monitoring and progressWe have few comments as monitoring is presently of a high standard in Australia. We submit that there are many areas where actions cannot presently be informed by high quality evidence. Critical evaluation of actions with uncertain effect, or magnitude of effect, should be built into all programs.
BarriersHistory clearly shows that it is not common for Governments, State and Federal and regardless of political colour, to implement concurrently a range of novel tobacco control initiatives. Therefore, as the desirable and necessary actions are many, rethinking this attitude of Government(s) is a basic requirement.
Further, there are other important actions that will follow from the report of the Preventative Health Taskforce and that are set to be implemented by the Australian National Preventative Health Agency. We support these but are concerned that ‘action fatigue’ may develop and the importance of tobacco control may be diffused.
Finally, it is apparent that we are entering a period during which there will be attempts to limit Government expenditures. This may be a barrier but there are many proposed actions for which the cost can be transferred effectively to manufacturers, distributors and retailers.
1. Priority Area 1– Strengthen social marketing campaigns to discourage uptake of smoking; motivate smokers to quit; prevent relapse; and reshape social norms about smoking;
Priority areasWe support the priority areas as stated. There is limited comment on the use of new media in promotion of cessation and the support of quitters. The recent Cochrane review 'Mass media interventions for preventing smoking in young people', identified social media as a vehicle that needs to be explored. Traditional media campaigns utilising television, radio and print material may not be reaching nor having an impact on many of the high risk youth that we are trying to target.
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6.1.1 Through 6.1.5 and 6.1.7It will be important that the whole of Government spend on social marketing, State and Federal, be maintained and preferably increased. Integration and sharing are the keys. An increase in Federal spend cannot be offset with a reduction at State level.
There is a place for a fully arms-length separation between program implementation and evaluation. Evaluation should ideally be of publication quality. This is likely to require an evaluation committee of social science and health academics. One of the key messages from a recent Cochrane Review is that evaluation does not match the good intent of many programs – notably but not limited to indigenous tobacco control programs.
6.1.6The introduction of plain packaging provides a particular time to re-focus the imagery and content of mass media. This is as always a complex development process. We submit that a key intent of the mass media should be to reinforce plain packaging as an effective strategy but also to be creative in the use of mass media to more effectively target youth at risk of smoking commencement 1.
6.1.8We are certain there will be great interest in plain packaging, associated media and outcomes!
Other actions to be implementedOther opportunities should be exploited to leverage existing Government programs. Mammography providers should be required to display material relevant to smoking women being screened. A smoking message should be included in material presented as part of the national bowel cancer screening program.
This is consistent with the evidence that, for participating smokers, smoking cessation produces a substantially greater benefit than their participation in these programs.
Priority Area 2- Continue to reduce the affordability of tobacco products
6.2.1We believe that there is no further need for analysis. The most recent quantum increase was effective including in vulnerable groups who, as recommended, require support. This is consistent with a large amount of evidence include disclosed internal tobacco industry documents.
6.2.2We believe that the remainder of the proposed substantial price increases as proposed by the Preventative Health Taskforce should be delivered as soon as possible. The aim should be that subsequent excise increases are, for the sake of providing a figure, a minimum of 5% annually or CPI +2%. The message should be clear.
6.2.3 and 6.2.4We support the need to provide clinical care support for lower SES smokers and others who are vulnerable to the initial economic impact of price increases. As such there is a need for specialized training for all health care workers who are caring for these patients as there is a need for easy access to effective medication to quit smoking – either in advance of a price increase and/or to palliate withdrawal symptoms.
6.2.5In the event that the full implementation of initiatives such as Plain Packaging or other subsequent action leads to a discounting ‘war’, the Government should be prepared to rapidly implement irreversible excise increases and to hold these as the base for any further scheduled increases
6.2.8 and 6.2.9There should be vigilance but not, based on current data, fear of illicit trade. Overstating the potential impact of illicit trade is clearly a tobacco industry tactic. A preliminary consideration of a ban on the sale of all forms of loose tobacco, excised or not, is a worthy notion.
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6.2.10We welcome the recent budget duty-free decision. All sales points, departure or arrival, must fully comply with out-of-sight laws and other standard retail regulations as mandated from time to time.
Priority Area - 3– Bolster and build on existing programs and partnerships to reduce smoking rates among Aboriginal and Torres Strait Islander people.
The Lung Health Alliance supports absolutely the need to reduce and, to do so rapidly, the harms of smoking in indigenous Australians. Lung Health is severely impacted upon by smoking. As members of the Australian community, concern over these harms might be reasonably extended to Maori living in Australia. Although not indigenous to Australia the pattern of tobacco use and harms is similar.
We are certain that there will be considerable endeavor in this area but we argue for a brief pause to consider whether evaluation strategies are in place and adequate – as described in 6.3.2. We provide the following quote from a recent Cochrane Review2 , the principles which we support.
"Of note, no methodologically rigorous evaluations alongside governmental policies were identified for this review despite the large monetary investments publicised for Indigenous smoking cessation strategies. These policies (which can include mass media campaigns, access to free nicotine replacement therapies etc.) require considerable resources; however their subsequent efficacy to increase long-term smoking abstinence following implementation is unknown. The use of such resources for programs with unproven effectiveness in the Indigenous context can have a detrimental result, as resources provided for the delivery of ineffective interventions means an opportunity cost for other interventions….
….. As such, the next phase in tobacco cessation strategies for Indigenous populations must include accompanying assessments to determine the success of the intervention, efficacy of its implementation and ability for mass-dissemination. This does not necessarily dictate that a heavily funded double-blind randomized controlled trial is required. Rather, an assessment involving descriptive and qualitative data to determine the likely success following the transfer of interventions to the Indigenous setting may suffice."
Once the evaluation structure is in place, we strongly support the breadth of actions proposed in the draft policy. We caution that a rigorous evaluation may lead to the discontinuation of some programs but that is its purpose.
We fundamentally believe that the answer to indigenous smoking rates rests with the neutering of tobacco as an addictive productive whose unpleasant aspects are masked by additives. Further, we believe that, to achieve the rapidity of decrease in smoking rates as outlined in this policy, a product change will be required.
Although a number of interventions and educational actions had been undertaken to reduce the harms of petrol-sniffing and other volatile substance use in indigenous communities, it was fuel substitution finally culminating in the implementation of OPAL fuel that saw reductions in sniffing of the magnitude of smoking reductions that are being sought in the coming 5 years3. This is not to say that other actions are unwelcome or unnecessary but it would be foolish not to learn from history.
Priority Area 4- Strengthen efforts to reduce smoking among people in disadvantaged populations with high smoking prevalence;
The evidence is that price increases help the disadvantaged rather than harm them and this should be considered part of the evidence base for price increases. This is previously discussed as is the need for support for smokers.
As we come from a health background, we are compelled to note that one solution to the problems of incarcerated smokers from ATSI background and/or who have a mental illness is to implement a whole of government review of the need for, benefits from and alternatives to incarceration in these marginalized groups.
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As per our comments in relation to ATSI smokers, the initiative with the greatest reach into marginalized groups is that which would reduce the addictive nature of the product itself. These are known – see below under product and additives regulations.
Management of the potential added harms of increased tobacco prices on vulnerable people in correctional settings is required. The ultimate solution without question is tobacco-free correctional facilities with the assurance that treatments to address the short-term symptoms of nicotine withdrawal are provided. There has been a partial implementation in facilities in Australia and more complete bans in other countries, notable NZ. These implementations have been successful.
Facilities providing care for patients with mental illness, whether inpatient or ambulatory, should have in place effective management for staff and patients who are tobacco smokers and should be smoke-free. The existence and implementation of these policies should be an important consideration in facility accreditation and required for receipt of Government funding.
Priority Area 5– Eliminate remaining advertising, promotion and sponsorship of tobacco products
6.5.1 through 6.5.3As with other health charities, we strongly endorse the plain packaging laws and new pack warnings. Regular feedback to interest groups so as to continue their active involvement and thereby to increase the extent of public support for these actions is of value.
6.5.4Rather than simply investigating the possible benefits of requiring tobacco companies to report regularly on expenditure on any form of tobacco promotion and marketing, we favour simple implementation. It is not clear to us how the extent of benefit from disclosure could be determined and the enquiry itself would be a cost. It is better for open disclosure to be required regardless of effect.
6.5.6We support immediate elimination of all signage and promotion at POS. We acknowledge that States have substantial carriage. All possible forms of influence should be brought to bear to achieve a uniform satisfactory outcome.
6.5.7We are not experts on the matter of social media, the internet and alternate forms of TAP but we trust that the Government will heed the advice of others with that expertise. It is self evident that the tobacco industry will try to use these avenues to promote sales and to diminish the effect of other implemented actions.
6.5.9No shopper rewards schemes of any type should be permitted. Participants in programs such as Fly Buys should not be awarded points for tobacco purchases. As the schemes are now, there are already exclusions and bonuses for certain products and this proves exclusion to be possible. Credit card level restrictions are likely not possible.
6.5.10It is critical that the Government and all related parties fully address issues raised under article 5.3. We support all actions in this regard.
6.5.11We are not convinced that a large effort should be devoted to smoking and the movies although we continue to note with regret the high rate of portrayal of smoking and we fully accept that this has an effect. There may be lower hanging fruit for the effort.
Further actionsGiven that the technology clearly exists, we submit that re-runs of old sporting events, that were sponsored by tobacco companies or carry tobacco advertising, should have that advertising blanked out.
Consistent with our international obligations, sporting bodies must be required to warrant that any and all advertising carried as a consequence of staged events is not related directly or indirectly to tobacco products. The events of 2011/12 involving an Indian tobacco product and Australian Cricket Board should not be repeated.
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Priority Area 6- Consider further regulation of the contents, product disclosure and supply of tobacco products and non therapeutic nicotine delivery systems;
6.6.1We do not support the commissioning of research. Action is required instead. There should be a full disclosure of all substances added in the manufacturing process as well as all forms of pesticides and chemical residues that might be related to any agricultural practice.
6.6.2“Contrary to the view that PM "lucked" into the highly successful Marlboro, it is logical to assume that the Marlboro was a systematically designed cigarette incorporating results from the basic biological, behavioral, and product research PM had conducted over a period of many years. The results from more recent research permit PM to systematically modify the Marlboro in a logical manner4 ”
In relation to additives along the lines of flavourings etc, we do not support the commissioning of research. The presumption must be that, if any substance is included in remanufactured tobacco, it has a function. There is extensive documentation of this in material released under the Master Tobacco Settlement. The only form of research that could be commissioned could be short-term cigarette palatability studies and use persistence.
We consider the exclusion of all additives as one component of a strategy. There are some concerns that some additives can also be naturally occurring and therefore that monitoring and sanctioning may be problematic. The monitoring would presumably be a cost to Government.
There is a major issue with selective bans. In general, the evidence base for which additives should be banned and the consequential effects is uncertain and will remain uncertain. Moreover, if the exclusion of one or a number of additives does not achieve the desired effect, or a workaround is created by the tobacco industry, a complex iterative process may develop without necessarily or quickly achieving the aim. Further, the specification of some additives as permitted and others as banned may create an ironic situation where the Australian Government is specifying a cigarette design. Who owns the legal risk of smoking in this setting is beyond our expertise but may be worthy of consideration by the Solicitor-General.
Our belief is that the issue of nicotine availability in tobacco smoke, that is clearly critical to the establishment and maintenance of the addicted state, should be addressed within the term of this policy. The tobacco industry’s own experts and experience is such that these cigarettes are unattractive to smokers and will not sell .
The three elements of our suggestions are:
1. Low upper limit on smoke nicotine delivery similar to that of the de-nicotinised, Next-type cigarette (rather than the sort of cigarettes previously described and marketed as “mild” or “light” cigarettes)
2. Upper limit of smoke pH as alkalinizing smoke enhances nicotine delivery
3. Ban on the use of any additives in the manufacturing process
This approach would be entirely consistent with the National Drugs Strategy 2010-2015.
Many of the actions in this draft policy will address the first pillar – Demand Reduction. The second pillar, Supply Reduction is not in immediate focus but we note that it is included in concepts that are encompassed in the so-called “end-game”. The third and important pillar is Harm Reduction. Tobacco is harmful primarily because it establishes and maintains the addicted state. By and large, smokers do not persist with the use of nicotine-depleted cigarettes and there is an excellent case prima facie that such cigarettes would not create the addicted state in young people. We argue that to comply fully with the National Drug Strategy, product specifications of the type noted should be investigated early in the 2013-2018 period with their planned introduction in 2016.
As lung health charities, we know that the notion of removing the addictive elements of a harmful product is neither novel nor revolutionary and is effective. Compulsory reformulation of compound analgesics and the eventual ban on over-the-counter sales in the late 1970’s effectively reduced consumption and has been followed by dramatic reductions in analgesic nephropathy and other harms of compound analgesic abuse6 . It stands as one of the great achievements of Public Health by regulation. Importantly, the products were never banned outright but their use just faded away. Further support for this approach, as previously mentioned, is that fuel substitution has been an effective strategy in the minimization of harms from fuel-sniffing in some communities.
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In parallel, the temporary problem of withdrawal will have to be addressed with NRT through public information and existing availability and subsidy policy.
Our strong support of such actions reflects our belief that only the elimination of a tolerable, addictive cigarette will truly address the harms of smoking in the most vulnerable groups identified in the draft policy and is the cheapest, effective actions as the full costs are transferred to the tobacco manufacturer.
6.6.5As it relates to e-cigarettes, we are opposed to all forms of non-tobacco nicotine that are not developed, proven safe and sold with standards of approved pharmaceuticals. The appropriate national approach to supply is to ensure that there is compliance with the Therapeutic Goods Act. There will also need to be policy development in the area of promotion and advertising in parallel with this. E-cigarettes should be banned and their use otherwise restricted using any and all means available to Government.
6.6.7To avoid the current legal situation with PM Asia(Hong Kong) suing the Australian Government, we ask whether it is possible that a manufacturer/distributor licence be created such that all tobacco sold in Australia must be sold by a registered Australian business entity. This entity would be required then to fully comply with laws and carry the risk of product liability.
We support retailer licensing - this as a necessary prelude to action under 6.6.8 and to ensure that other actions can be implemented, monitored and enforced. The existence of a licence creates the possibility under law that a sanction for non-compliance with law or regulations could be the temporary or permanent loss of that licence.
Regulatory costs in all cases should be met by licence costs and the payment of a retailer’s licence fee by a tobacco manufacturer or distributor should be banned.
6.6.8There is excellent evidence that the ‘recently quit’ smoker, an individual who deserves protection, is vulnerable to relapse with cigarettes obtained from vending machines or convenience outlets. Therefore, we strongly support effective action to limit the number and type of tobacco outlets. We understand that there are both State and Federal actions required and that there will be concerted retailer actions in response to this. However achieved, vending machine sales should be banned.
Priority Area 7- Reduce exceptions to smoke-free workplaces, public places and other settings
The Lung Health Alliance represents the interests of many people living with lung disease, or at risk of it. In order to have full, safe participation in all aspects of life, comprehensive smoke-free legislation is required. We understand that there are jurisdictional issues and that all three levels of Government, together with corporate and private structures play a role but the end result should be the same.
WorkplacesWhere workers are there should be no smoke exposure. There should be no possibility for a smoker to assume an occupational risk for any reason. We do not accept safety compromise in any other work place. This requires that there be no smoke in places where food and beverages are served and/or which are serviced/ cleaned. It also requires that exemptions in casinos should be ended.
Protection of childrenAll places where children congregate must be smoke-free.
Dwellings/carsWe support public information campaigns for smoke-free homes and a combination of education and regulation for smoke-free cars when carrying children.
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Multi-Unit dwellings (MUD)We applaud the efforts of Action on Smoking and Health in promotion and facilitation of smoke-free MUD. Initially we believe that education, information and facilitation are required with regulation following if it is evident that action has not followed from these alone.
Priority Area 8– provide greater access to a range of evidence-based cessation services to support smokers to quit.
This is an area of considerable controversy in two areas.
1. Cold turkey vs assisted cessation
2. The value of smoking cessation clinics
It is clearly true that cold turkey is the most commonly used quit strategy. It is also true that the most recent quit attempt, if successful, was most likely to be based on cold turkey. However, it is misleading, bordering on mischievous, to draw from these facts that ‘cold turkey’ is the optimal strategy or as expressed by some commentators and reflected in the draft ‘the most successful method.’ It is entirely possible that 6 cold turkey failures could be followed by a success that might have been achieved months or years before with a pharmacotherapy.
The Lung Health Alliance believes that there must be balance.
1. Care must be taken in the promotion of approved smoking cessation therapies that the impression is never left that unassisted cessation cannot work. The most important outcome of public information campaigns is a higher number of quit attempts. This requires the co-operation of Pharmaceutical Companies who develop, promote and sell smoking cessation products.
2. Care must be taken in the use of data as presented here so that dependent smokers who have been shown in validated trials to benefit from a smoking cessation therapy are not put off their use
As relates to smoking clinics, there is quality evidence that the full UK implementation of smoking clinics is good value compared to other endeavours but also that its likely population impact is limited. That is, they may be well worthwhile health care investments but not the solution to achieving rates of 10% or less and the required reduction in groups at special risk.
Rather than creating a new class of smoking cessation professionals, it may be more useful to retrain or upskill existing health care workers7 . Mandatory CPR training is required in many health workplaces where CPR will likely not be required but almost all HCW should be required to identify smokers and advise cessation. This could be corrected with National Registration requirements.
Specifically current smoking status ascertainment and universal cessation advice have great potential for effect and implementation and should be a part of any revision of the RACGP guidelines.
QuitlinesThe quitlines are an important institution in tobacco control. One review that is worthwhile is into their function and reach. Are they providing general information on smoking or more specific quit advice? What is their reach into the pre-quitters, current quitters and those at risk of relapse?
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We support the development of alternate forms of cessation information delivery whether under the auspices of the QuitLine or otherwise. Much of the basic information, from detailed facts to simple tips, is repetitive and could be delivered through multi-media; YouTube etc.
1. Brinn MP, Carson KV, Esterman AJ, Chang AB, Smith BJ. Mass media interventions for preventing smoking in young people. Cochrane Database of Systematic Reviews 2011; Issue 8: Pages 1-59 Art.No.:CD001006. DOI.:10.1002/14651858.CD001006.pub2
2. Carson KV, Brinn MP, Peters M, Veale A, Esterman AJ, Smith BJ. Interventions for smoking cessation in Indigenous populations. Cochrane Database of Systematic Reviews 2012; Issue 1: Pages 1-52 Art.No.:CD009046. DOI:10.1002/14651858.CD009046.pub2
3. Midford R, MacLean S, Catto M, Thomson N, Debuyst O (2011) Review of volatile substance use among Indigenous people. Australian Indigenous Health Bulletin 11(1).
4. Biological/Consumer Preference Research Conducted by Philip Morris. Rodgman A, Colby FG.
5. Deposition of John H Hager. United States District Court for the Eastern District of Pennsylvania. June 28, 1997.
6. Chang SH, Mathew TH, McDonald S. Analgesic Nephropathy and Renal Replacement Therapy in Australia: Trends, Comorbidities and Outcomes. CJASN 2008; 3: 768-776
7. Carson KV, Verbiest MEA, Crone MR, Brinn MP, Esterman AJ, Assendelft WJJ, Smith BJ. Training health professionals in smoking cessation. Cochrane Database of Systematic Reviews 2012; Issue 5: Pages 1-144 Art.No.:CD000214. DOI.:10.1002/14651858.CD000214.pub2
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