Introduction

This is the third, immensely expanded edition of Tobacco in Australia: Facts and Issues, a project originally conceptualised by Paul Magnus, a founding director of ASH (Action on Smoking and Health Australia) and first published in 1989.1 The first edition, compiled by Margaret Winstanley and ASH director Stephen Woodward, and the second (1995) edition, by Winstanley, Woodward and Noni Walker,2 rapidly became the standard compendia of tobacco control-related information for Australia, sitting alongside the US Surgeon General's reports on smoking as indispensable source books, consulted almost daily by us all. No person seriously interested in any aspect of both the tasks facing tobacco control in Australia, and in learning what had happened so far, could afford to be without the early editions of the series.

When the first edition was published in 1989, the tobacco control landscape in Australia was vastly different than we find it today as we near the end of 2008. Tobacco excise tax was levied by weight, not by stick, resulting in a globally unique situation in which Australian tobacco companies were able to offer smokers 'bonus' cigarettes at discounted prices in packs of 25, 30, 40 and even 50 (see Chapter 13 , Section 13.3.1.2). This changed in 1999 when the Howard government finally changed the tax regimen to a per stick system, following a series of incalculably important treasury submissions written by Michelle Scollo for The Cancer Council Australia and National Heart Foundation.3 Tobacco advertising still wallpapered our visual environment in outdoor, print, shopfront and in-store media. Sporting and cultural sponsorship by tobacco companies greeted every cricket, rugby league, AFL, motor-racing, ballet and opera follower, with sporting stars and administrators dutifully defending the practice. Bans on smoking inside workplaces were in their early days, with the Commonwealth Public Service leading the charge from 1987. Airlines operated the infamous 'magic line' policy in which an arbitrary line separated the smoking and non-smoking sections. The problems here were that somebody forgot to tell the smoke that it should stay in the smoking section and that stewards were required to service the smoking areas. The idea that smoking would be one day outlawed in restaurants and bars was almost unthinkable to most ordinary Australians.

Tobacco packaging had carried warnings since 1973, but these were relatively small and limp and following many years of successful tobacco industry lobbying, remained silent on death ('smoking kills') or addiction.4 Tobacco industry operatives routinely appeared in the media denying that nicotine was addictive5 and that there was any proof that smoking was harmful.6 The Australian Tobacco Research Foundation7 continued to fund researchers such as the late Professor Mike Rand from the University of Melbourne who was a publicised smoker8 and whose views on nicotine addiction were helpful to the industry's public position. We had not then had the benefit of the tsunami of revelations from internal industry documents, which became publicly available from 19959 when California's Stan Glantz received several boxes of often highly illuminating documents from an anonymous whistleblower.10 In the years that followed, the flow of documents arising from the US Master Settlement Agreement—which included many thousands from and about Australia—would change the terms of debate about tobacco control forever. Decades of public denial by the tobacco industry about health risk, addiction and its ambitions to interest children in smoking were overnight exposed as lies, revealed via copious examples of admissions in their own internal documents.

Today, Australia ranks with Sweden, Canada and the USA as having achieved the largest falls in daily smoking prevalence of any nation.11 There are some Asian nations (such as the Chinese special administrative region of Hong Kong, and Singapore) and some countries in west Africa (for example Ghana and Nigeria) which have a lower smoking prevalence than Australia does (see Chapter 1, Section 1.13) but this is mostly explained by their deep cultural proscriptions against female smoking. In nearly all Asian nations, women have very low smoking rates, so when you combine them with men, several Asian nations have a lower combined sex smoking prevalence than Australia. But few nations have lowered smoking further than has Australia.

This is now paying huge dividends in reduced health problems. Remarkably, one has to go back to the early 1960s to find rates of male lung cancer as low as they have fallen today (see Figure 1).12 With 83% of lung cancer in Australia occurring in people who have smoked over many years13 and the very low five-year survival times after diagnosis having changed little over decades,14 most of this decline is directly attributable to effective tobacco control. Similarly, with chronic obstructive pulmonary disease (COPD), 72% of deaths are attributable to smoking13 and so the even larger falls in COPD deaths in Australia over the past 50 years again are largely a tribute to the downturn in smoking.12 By any world standard, Australia has done a lot of things right and has long been considered15 a global 'poster boy' model for many aspects of comprehensive tobacco control.

Four eras

Since the early 1960s when the early evidence about the harms caused by smoking was first consolidated, it might be argued that Australia has seen four broad eras of contemporary tobacco control:

Era 1 ran from about 1962 to 1973. These were 11 years during which newspapers often publicised the emerging bad news about smoking and health, but also when governments failed to introduce any tobacco control measures despite advice from peak agencies such as the National Health and Medical Research Council to do so.16 It was in this era that the late Cotter Harvey, the founder of the Australian Council on Smoking and Health (ACOSH), and Nigel Gray, then head of the Anti-Cancer Council of Victoria, laid the foundations of modern tobacco control.17, 18 Driven almost entirely by negative news coverage and in the absence of any of the platforms of modern tobacco control policy and practice, tobacco use started heading south, never again to head upward.

Era 2 from 1973 to 1982 saw the first health warning peeping off the bottom of cigarette packs4 and on advertising and thanks to the Whitlam and Fraser governments, the first body blow to tobacco advertising, with the ban on TV and radio advertising that entered into force in September 1976. The downward slide in smoking picked up speed. Early experimental work with mass media campaigns19 occurred in this era, with these becoming mainstreamed in mass reach campaigns from the early 1980s.20

Era 3, between 1982 and 2006, saw the commencement of the first sustained government Quit campaigns in NSW and Western Australia, which were quickly followed by most other states. It also saw: the funding by the National Heart Foundation, the Australian Cancer Society and all state cancer societies of anti-tobacco lobbying agency, ASH (Australia); the first comprehensive state (South Australia) Act addressing tobacco control21 ; the world's first use of hypothecated taxes (in Victoria) to buy out and effectively end tobacco sponsorship;22, 23 and in the early period, the heyday of the civil disobedience group BUGA UP24 which radicalised the tobacco advertising debate and made it suddenly more respectable for previously conservative medical associations and colleges to rattle the legislative cage. Era 3 also saw the emergence of the secondhand smoke juggernaut, turbo-charged with accumulating evidence by the mid-1980s, which denormalised25 smoking forever. Reduced smoking opportunities caused by smokefree policies precipitated an unprecedented fall of about 20% in daily consumption by continuing smokers.26, 27

Today, we are in the early years of a fourth era of tobacco control. Nearly all the traditional platforms of comprehensive tobacco control have been checked off.

• Our cigarettes are among the most expensive in the world (although as argued in Chapter 13, Section 13.4 still inordinately affordable).
• Tobacco advertising has been made illegal in all 'above the line' media and has retreated into the largely unregulated internet and viral marketing (Chapter 11, Section 11.0).
• The battle to have public smoking exiled outdoors is almost over (Chapter 15) with the end of smoking in bars (from 2006) following restaurants (from 2000) and indoor workplaces (from 1987). Casino high-roller rooms remain the last bastion of a neo-Dickensian application of occupational health law, in which it is apparently acceptable to allow the very rich to ignore the occupational health rights of casino workers.
• Tobacco packs have been desecrated beyond the imagining of 30 years ago. Instead of smokers passing their friends a designer crafted box of social promise, smokers pass a photo of an unforgettable gangrenous foot, or a cancerous mouth (Chapter 12 Attachment 12.1). Global momentum is now building for plain 'generic' packs, showing only brand names and even larger graphic health warnings.28

On any global ranking of comprehensive tobacco control, Australia is in the top five nations. Tobacco industry giant British American Tobacco calls us, along with Canada, 'one of the darkest markets in the world'.29

Smoking and the industry which promotes it have become symbols of an incompatible antithesis of powerful value systems that daily evoke environmental concerns, the fresh food movement, oral freshness, clean air, concern for others, ethical business conduct, and, of course, health. Tobacco control, along with Australia's record in reducing the road toll and containing the HIV epidemic is routinely named as an example of the success of prevention. But as this milestone report points out, with more than 3.1 million people still smoking today,30 and tobacco still being the leading cause of death by a wide margin,31 there is much still to do.

The future?

Future watchers in tobacco control see several broad possibilities: tobacco use could go down at about the rate it has over the past decades; it could go down even faster; or it could go down for a few more years and then bottom out to a 'hard core' of smokers. A fourth option—a sustained rise in tobacco use—seems unimaginable unless governments were to become utterly complacent. So which of the first three scenarios is more likely?

If the recent past is our guide, we may see an acceleration of the decline that has occurred since the early 1960s. The gradient of the downward slope has increased since 1997 from an average annual relative decline of 7% in the early 1990s to one of over 10% in the past seven years.32 Importantly, youth smoking has fallen to the lowest levels ever recorded33 so the powerful cohort effect of this, if sustained, will further reduce adult smoking as the years progress.

Moreover, it seems likely that things will get even worse for smoking. Through its commitment to chronic disease prevention, the Rudd government has already shown interest in investing in tobacco control. If tobacco industry opposition is an important guide, the March 2006 pack warnings will be now twisting the knife very hard; as will the 2006–07 indoor area pub smoking bans. Retail displays are starting to disappear and plain, generic packaging are in the early stages of advocacy.34 All this suggests that the slow free fall we have been seeing will most likely accelerate. The next round of national smoking prevalence data, due in 2010, is highly anticipated.

A recently published Federal Government taskforce report35 has called for Australia to strive to reduce smoking prevalence to 9% or less by the year 2020—just 12 years away. Recommended measures include: raising the retail price of a packet of cigarettes to about $20 a pack, matching that of Ireland, currently the nation with the highest tobacco prices in the world; mandating plain packaging of tobacco products and increasing the minimum size for health warnings; boosting mass-reach campaigns, known to be powerfully influential with both adults36 and children37; banning displays of tobacco products at point of sale and modernising laws that prohibit marketing of tobacco products; banning smoking in cars and addressing remaining loopholes in laws protecting the public and workers in the hospitality industry; increasing penalties and enforcement of laws banning sales to minors; subsidising nicotine replacement therapy for low-income smokers, and ensuring that people receive encouragement to quit in every interaction with the health care system.

Hardening or softening?

The 'hard core' hypothesis (the idea that we have reached a point where the remaining smokers are deeply addicted and therefore unresponsive to the normal range of policies and interventions) has been discredited in a number of reports. O'Connor et al38 examined data from two cross-sectional US National Health and Nutrition Examination Surveys (NHANES), conducted in 1988–1994 and 1999–2002. Laboratory, examination, and interview data from current smokers not reporting nicotine intake from other sources were examined. From NHANES III (1988–1994) to NHANES V (1999–2002), the average number of cigarettes smoked per day fell by nearly 15% (three cigarettes), while the mean serum cotinine level fell by 13%. The authors noted that 'these data are inconsistent with the hypothesis that the remaining population of smokers is becoming more dependent on nicotine over time.' If it were true that the smoking population was 'hardening', the average number of cigarettes being smoked daily and smoker cotinine levels would be rising, not falling.

Regular surveys by the Anti-Cancer Council of Victoria show a steady reduction in the number of cigarettes smoked per day in all age groups (Table 1).

Data on smoking prevalence from the 2001 and 2004 Australian National Drug Household Surveys show that occasional, light and social smokers today comprise 62.7% of all smokers and heavy and 'chain' smokers comprise 37.3% of all smokers.39, 40

Estimates of truly 'hard core' smokers range from 5% to 14% of smokers in the USA,48, 49 to 16% in the UK.50 These are defined as heavy smokers with no interest in quitting. In Australia, an estimated 5.5% of smokers aged 26 and over meet the hard-core criteria.51 In Australia today, a large majority of smokers want to quit and the experience of 'regret' at having commenced is nearly universal.52 This presents the same challenges that it has for decades: to get lots of smokers to the cessation starting line to make quit attempts,53 offering them support and preventing relapse.

Ken Warner and David Burns54 in the USA conclude that while there are certainly sub-populations of hard-to-quit smokers—particularly among those with mental health problems—there is little evidence that the smoking population as a whole is 'hardening': cessation rates have not decreased; daily consumption among continuing smokers is falling (something wholly incompatible with the hardening hypothesis) and the prevalence of occasional smokers rising;55 truly hard core smokers comprise a small fraction of all smokers; and quitting-susceptible smokers continue to dominate the smoking population. The view that we will reach a granite rock bottom of (say) 10% of people smoking is widely considered to be pure pessimism and not supported by any good evidence.

So, how can we make sure we whip all this along harder? I believe we hold three aces that we need to champion and play hard and often.

Denormalisation

Community attitudes against smoking have never been stronger. The iconography of smoking today has radically changed from the ways Richard Klein saw it in his book documenting the way smoking came to connote a wide range of positive virtues.56 For decades smoking connoted a ritualistic, seductive, contemplative engagement that worked beautifully for the tobacco industry. Today, the public face of smoking is one of people at the back of every social queue, marginalised, regretful, apologetic, dependent, inconsiderate, resented for demanding work breaks, desperately trying to cover up the smell. While smoking might have once signified rebelliousness and style, today it often connotes a sad, bygone, sickly dependency. Winfield is hardly for winners: it's more often for marginalised people struggling in their lives; Peter Jackson smokers aren't laughing, as the ads used to say: they are more likely to be moping outside an office block, exiled from normal social company; and the notion that Alpine is 'fresh', again as its advertising used to say, is almost laughable.

Without advertising, this is unlikely to reverse. The widespread and growing antipathy about smoking has unleashed a vast 'reserve army' of ordinary citizens who are effectively tobacco control activists, increasingly expressing their preference for smokefree environments and urging governments to 'make smoking history'. Harnessing this large community as a force for advocacy for future policies such as further tobacco tax increases, generic packaging and bans on retail displays (already announced for NSW, the NT, ACT and Tasmania) should become a priority. Imagine if even one in four doctors became active advocates for 'finishing the job' in tobacco control.

While smoking was once normal, it is now increasingly abnormal. Smoking rates are high in certain populations (such as the mentally ill and the prison population, among whom a majority of individuals are smokers—see Chapter 1, Section 1.7 and Chapter 9, Section 9.6) and in many Indigenous communities (see Chapter 8) where urgent and sustained efforts are needed. However there is no age group or socioeconomic group in Australia in which a majority of people smoke. The old refrain that the poor are surrounded by smokers is no longer true. Someone waking from a 20-year sleep would be amazed how the cultural landscape of smoking has changed. By feeding new information and data into this mix via news and campaigns, we can continue to foment the cultural erosion of smoking.

The tobacco industry's pariah status

A vital part of denormalisation has been the way the tobacco industry has become a pariah industry.57 People routinely reach for analogies about the tobacco industry when they want to paint a word picture of ethical bottom-feeding.25 The tobacco industry has been thrown out of nearly every sporting, cultural, and academic forum in Australia, and even tossed from its own corporate nest: some corporate social responsibility meetings have excluded its participation.58 Highly popular TV programs such as The Chaser's War on Everything mercilessly satirise the industry.[1] As the American Cancer Society's John Seffrin put it, no politician wants to stand next to a pariah in the next photo opportunity.

It takes a certain sort of ethically anesthetised person to join the tobacco industry today.59 It is not where our brightest marketing graduates want to end up. A weak tobacco industry whose political presence is akin to being seen consorting with the Grim Reaper, can only assist tobacco control to grow even stronger.

Population orientation

In Australia, we have always understood instinctively that if we were to get on top of smoking, we needed to match the sheer size of the task with the strategies we bring to changing it. We have used mass reach legislation, tax, campaigns and advocacy to get tobacco control messages into the homes, offices, hearts and minds of millions of Australians.

There are some who are keen to see Australia go down the UK path and establish a national large network of dedicated smoking cessation clinics. However, a 2005 report60 examining the contribution of this massive program to meeting a target national UK smoking prevalence of 21% by the year 2010, stated:

'Nationally, stop smoking achieved a reduction in prevalence of 0.51% in 2003–04. If persisting up to 2010, this success rate would lead to a reduction in prevalence of 3.6% —i.e. from the current level of 26% to 22.4%. For stop smoking service alone to meet the target of 21%, in England the number of successful quitters each year would need to be 50% greater.'

However, in a remarkably understated next paragraph, the report continues:

'…since successful quitting [in these calculations] is measured by a self-report at 4 weeks and only 25% of smokers remain quit at 12 months … all the estimates of reduction in prevalence calculated in this report could legitimately be divided by four (my emphasis) – producing an overall reduction of 0.13% per year or around 1% (from 26% to 25%) by 2010 for England.'60

The above statement that 'only 25% of smokers remain quit at 12 months' also contrasts with a published evaluation of the program's cessation where, at one year, only one in seven (14.6%) of smokers who had attended the English tobacco treatment services were still not smoking.61 In 2005, Milne62 examined use of government supported smoking cessation services in two English regions with the highest numbers of smokers using such services. Comparable with the above caveat, he calculated an annual reduction in smoking prevalence in the region attributable to the cessation services of 0.12%, (a figure corrected later by others as 0.15%63 whereas the background quit rate was 1.5%–2%, 10-to-13 times higher).

This is not the way to keep the downward momentum going. Major investment in labour-intensive smoking cessation may threaten the resources dedicated to population focused campaigns.

Finally, let's consider a potential danger in the road.

Issue wear-out

Everyone working in tobacco control in Australia has heard others arguing that smoking has been 'done'. It is true that Australia's track record in reducing smoking and the diseases it causes does rank with AIDS control, immunisation and lowering the road toll as a modern public health success story. However more than three million Australians do still smoke, half of whom —if they continue to smoke long term— are very likely going to die while they are still in middle age. And yet until very recently, it had been a long time since smoking made it to the list of any urgent national health priorities. Obesity, suicide, breast cancer, 'bird flu', and bioterrorism have all been much more politically fashionable in recent years. The Rudd government's recent announcement of $14.5 million for Indigenous tobacco control over four years64 may be a sign of new thinking and the prominence given to tobacco control in the initial work of its Preventative Health Task Force65 seems to portend well.

In one sense, Australia is a victim of its own success. As we tick off each policy victory, we reduce potential media interest, a potent factor in promoting community debate and influencing policy change. For example, there are few news stories to tell about tobacco advertising when all tobacco advertising is banned. In the next decade we need to give a lot of careful and creative thought to how to continually refresh media, political and public interest in tobacco control. 'Finishing the job' and giving greater attention to hard-to-reach groups, especially the Indigenous community, will be the organising concepts.

The chief epidemiologist at the American Cancer Society, Michael Thun, has attributed the recent unprecedented downturn in total cancer mortality in the USA to smoking cessation, stating that  'without reductions in smoking, there would have been virtually no reduction in overall cancer mortality in either men or women since the early 1990s. The payoff from past investments in tobacco control has only just begun.'66 Australian data dramatically illustrate the benefits of declines in smoking on public health, as well as the public purse.   A report to the Australian Department of Health and Ageing assessing the returns on investment in public health estimated that the 30% decline in smoking between 1975 and 1995 had prevented over 400,000 premature deaths67 and saved over $8.4 billion, more than 50 times the amount spent on anti-smoking campaigns over that period.68

As we proceed towards what well might be the final era of tobacco control in Australia, this new edition of Facts and Issues is destined to become one of the field’s most widely consulted publications. Its many contributors deserve much praise. The importance of our current endeavour should not be underestimated, for nothing could have a greater impact on public health in Australia than 'making smoking history'.  

[1] See http://au.youtube.com/watch?v=OkhbAAbD3iE and http://au.youtube.com/watch?v=3mAUQGHcIoU&feature=related

• Home
• Foreword
• Acknowledgments
• Introduction
• Chapter 1
  Trends in the prevalence of smoking
• Chapter 2
  Trends in tobacco consumption
• Chapter 3
  The health effects of active smoking
• Chapter 4
  The health effects of secondhand smoke
• Chapter 5
  Factors influencing the uptake and prevention of smoking
• Chapter 6
  Addiction
• Chapter 7
  Smoking cessation
• Chapter 8
  Tobacco use among Aboriginal peoples and Torres Strait Islanders
• Chapter 9
  Smoking and social disadvantage
• Chapter 10
  The tobacco industry in Australian society
• Chapter 11
  Tobacco advertising and promotion
• Chapter 12
  The construction and labelling of Australian cigarettes
• Chapter 13
  The pricing and taxation of tobacco products in Australia
• Chapter 14
  Social marketing and public education campaigns
• Chapter 15
  Smokefree environments
• Chapter 16
  Tobacco litigation in Australia
• Chapter 17
  The economics of tobacco control
• Chapter 18
  The WHO Framework Convention on Tobacco Control
• Appendix 1
  Useful weblinks to tobacco resources