INFORMATION. Tobacco Control Policy. Information from the

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Tobacco Control Policy

Background

Cigarette smoking is a major cause of heart attack, stroke and peripheral vascular disease and is the largest single preventable cause of death in Australia, killing over 19,000 Australians a year.1

In 1998, approximately 3.5 million Australian adults (around 23% of the adult population) smoked on a regular basis and were at risk of developing heart disease and other chronic conditions from smoking.2 The prevalence of smoking is significantly higher among adults

from socio-economically disadvantaged groups and Aboriginal and Torres Strait Islander people.2

Disturbingly, although adult levels of smoking have fallen considerably in recent decades, the levels of smoking by teenagers have not mirrored this rate of decline, with about 70,000 teenagers starting smoking each year.3In 1999, around 269,000 boys and girls at

school, aged 12 to 17 years, were current smokers.4 If all of these students were to

continue smoking, it is estimated that about 134,000 would die prematurely from their smoking habit.4

In addition to causing premature death, smoking significantly reduces quality of life5and

places a huge financial drain on the health sector, as well as the broader community.6 In

1992 for example, health economists estimated that the direct and indirect costs of

smoking to Australia were $12.7 billion.6 These costs include health care expenditure, lost

productivity and costs of treatment for, and prevention of, tobacco addiction.

There are many barriers to reducing smoking: nicotine is addictive; new consumers are impressionable adolescents; cigarettes are widely available and affordable; and there is active opposition from the tobacco industry to reducing smoking. The enormous profit of tobacco companies exerts political influence.

The Heart Foundation supports the World Health Organisation’s7(WHO), criticism of

tobacco industry efforts to conceal the health effects of smoking and for deliberately casting doubts on the links between smoking and health. This has hampered government anti-smoking efforts and probably impeded individual assessment of the health risks of smoking.7

If current smoking patterns persist, then by 2025 there will be about 10 million deaths a year globally from tobacco, 3 million in developed and 7 million in developing countries.8

Evidence

Cigarette smoking is a major cause of a number of forms of cardiovascular disease, including heart attack, stroke, peripheral arterial disease and abdominal aortic

aneurysms.9,10Evidence for a relationship between smoking and coronary heart disease

(CHD) has been accumulating since the 1940s.11In 1983, the US Surgeon General10

conducted the first major review of the epidemiological and biological evidence of the relation between smoking and cardiovascular disease. The review concluded:

• smokers have a 70% greater risk of death from coronary heart disease (CHD) than non-smokers;

• the risk of CHD is directly related to the dosage of cigarette smoke exposure, with heavy smokers (2 packs a day) experiencing CHD mortality rates almost 200% greater than non-smokers; and

For more information contact Heartline 1300 362 787 or www.heartfoundation.com.au

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• cessation of smoking results in a substantial and rapid reduction in CHD death rates. Approximately 10 years after stopping smoking the death rate of ex-smokers from heart disease is about the same as for life-long non-smokers.

In developed countries, cardiovascular disease, in particular ischaemic heart disease, is the most common smoking related cause of death.12Around 13% of deaths from cardiovascular

disease in Australia (the leading cause of death) are attributable to tobacco smoking.12 In

1998, this represented over 6,600 deaths from cardiovascular disease.2 Smoking is

responsible for a large proportion of heart attacks among younger cigarette smokers, who are otherwise at low risk of coronary heart disease.13

There are other effects of smoking above the direct impact on the individual smoker. Passive smoking, or the involuntary breathing of other people’s cigarette smoke, increases a person’s risk of heart disease by about 25%;14it also increases the risk of stroke.15 Even brief

exposure to passive smoking (e.g. for as little as 30 minutes) can affect the cardiovascular system of non-smokers.16,17 The children of smokers are at greater risk of a number of

respiratory and other health problems due to exposure to passive smoking,18,19and are more

likely to become smokers than the children of non-smoking parents.20

Taking action to reduce tobacco use

The tobacco control field has long recognised the need for a comprehensive approach to reduce use21and several recent reviews have documented the key elements of an effective

tobacco control policy.22–34 International evidence shows that well funded, comprehensive

tobacco control programs can successfully reduce tobacco use. In California for example, mass public information and media campaigns, funded by tobacco taxes, have had a major influence on smoking behaviour.25 The prevalence of smoking was reduced from 23.5% in

1988 to 18% in 1996. A 50% more rapid rate of decline in per capita consumption was measured in California when compared to other states.25California’s comprehensive tobacco

control program is estimated to have prevented 33,000 deaths from CHD during its first seven years.26 The cost of running California’s comprehensive tobacco control program has

been offset by the short-term savings in direct medical costs associated with heart attacks and strokes prevented.27

In Australia there are also a number of examples of success in the reduction of tobacco smoking resulting from a combination of legislative, educational and economic approaches. Australia’s National Tobacco Campaign was launched in 1997 and is a collaborative smoking cessation initiative of federal, state and territory government and non-government

organisations. Campaign evaluation indicates that there was an overall reduction of about 1.8% in the adult prevalence of smoking in Australia over the first 18 months of the Campaign.28 An economic evaluation estimated that, in the Campaign’s first six months

alone, 922 premature deaths were potentially prevented and there was a cost saving of up to $24 million in health expenditure.28

Despite the achievements of the National Tobacco Campaign and other state and territory based tobacco control efforts, comparisons with other countries indicate there are

opportunities to decrease smoking further in Australia, with more lasting effects achieved by preventive action coordinated through health sector partnerships and alliances with other sectors.29

The National Heart Foundation of Australia’s position on tobacco

• The Heart Foundation promotes a reduction in smoking as a leading priority in the promotion of cardiovascular health.

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• The Heart Foundation’s policy is to use advocacy and education to discourage smoking, especially its uptake by children, to encourage and assist current smokers to stop smoking, and to prevent involuntary exposure to tobacco smoke.

• As a health research-funding organisation, the Heart Foundation will not support individuals, research groups or research institutions who accept any money by way of research grants, consultancies or sponsorship from the tobacco industry or persons connected with the tobacco industry. This includes direct funding, as well as advertising, sponsorship, gifts or loan of goods or services, or funding by any other means.

• The Heart Foundation will not accept donations or accept sponsorship from the tobacco industry.

• The Heart Foundation is a smoke-free workplace.

• The Heart Foundation promotes a smoke-free culture – an environment free of tobacco smoke that is supported by the community.

Recommendations

The Heart Foundation endorses Australia’s National Tobacco Strategy (1999)30and its key

strategy areas are reflected in Heart Foundation policy and programs. The Heart Foundation also endorses the more recent framework, Tobacco Control: a blue chip investment for public

health,31which provides a comprehensive framework for future tobacco control efforts and

expenditure in Australia and delineates actions that can be taken by federal government, state and territory governments and non-government organisations. At an international level, the Heart Foundation is a signatory to the Framework Convention on Tobacco Control

(FCTC), an international treaty that is being developed to establish international guidelines for tobacco control.

The Heart Foundation recognises the responsibility of the federal and state government and non-government agencies to work together to implement effective and comprehensive tobacco control programs for Australia.

The following goals and strategies reflect the Heart Foundation’s policy on tobacco and are complementary to the framework provided by the National Tobacco Strategy30and that

incorporate relevant recommendations of the Tobacco Control: a blue chip investment for

public health report.31

GOALS STRATEGIES

Ensure long-term financial commitments to tobacco control funding, including mass media campaigns designed on sound behavioural principles and market research, by identifying potential funding bodies (governments, business, health sector) and potential sources of funding (licence fees, litigation, taxation). Encourage development of proposals, direct lobbying and media advocacy to support investment by potential funding bodies.

Encourage governments conducting anti-smoking campaigns to include programs and placement in media popular among young people.

Devote an increased proportion of Heart Foundation prevention education budgets to policy development and advocacy in tobacco control.

Conduct adequately funded nationwide mass media and education campaigns.

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GOALS STRATEGIES Lobby for:

• Continuation of six monthly indexation of tobacco excise and customs duty;

• bi-annual increases of duty in line with AWE and estimates of children’s average weekly disposable pocket money;

• prevention of evasion of customs and excise duty on tobacco products.

Encourage the introduction of tobacco packaging requirements that include generic packaging; a mix of warnings, pictures and cessation messages; and pack inserts that will help to reduce uptake, prevent relapse and maximise quitting intentions. Package warnings and information should change on a regular basis and be integrated with messages provided by national mass media and education campaigns. Packs should also include a national Quitline number and details of the content of ingredients, additives and various toxins in the brand’s smoke, and the average and maximum toxic output of tobacco products when smoked.

Encourage government action to:

• provide health warnings and cessation information at outlets where tobacco is sold;

• introduce new rotating warnings and inserts that are research based and integrated with national mass media and education campaigns;

• prohibit the use of misleading terms such as ‘mild’ and ‘light’ in the marketing of tobacco products;

• prohibit all point of sale tobacco advertising;

• ensure complete and effective disclosure by tobacco companies of information pertaining to product

contents and toxic outputs, marketing activities, health risks and sales.

Develop a policy for regulation and eventually prohibition of the use of additives unless approved by an independent national testing agency.

Encourage governments to investigate the potential for reductions in the addictive potential of tobacco products.

Encourage governments to establish enforceable and industry-wide targets for a reduction in levels of carcinogens and other toxins in tobacco smoke.

Produce the following outcomes through litigation: • publicly expose the history of unlawful conduct of the

tobacco companies (including through the discovery of incriminating industry documents) and demonstrate the ongoing effects of that conduct.

Ensure cigarettes do not become affordable to children. Ensure adequate information is provided to consumers of tobacco products. Prohibit manufacturing processes and/or additives that improve palatability, increase addictiveness and/or increase harm of tobacco smoke.

Mandate a reduction over time in the average levels of carcinogens and other toxins in tobacco smoke. Undertake litigation to support tobacco control initiatives.

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GOALS STRATEGIES

Hold the tobacco companies accountable for the effects of their unlawful conduct, and require them to:

• compensate those who have already been harmed by the conduct;

• take positive steps to reduce the likelihood of future harm caused by this conduct.

Emphasise the areas in which the tobacco companies continue to act unlawfully (whether under Trade Practices legislation, criminal law or at common law) – as a means to:

• obtain court orders directing them specifically to do, or refrain from doing, certain things;

• achieve stronger government regulation on both tobacco products and tobacco companies.

Establish the right of patrons and employees to safe and healthy workplaces and public places.

Encourage governments to:

• extend regulation of tobacco marketing to include transmission of overseas sporting events sponsored by tobacco companies and promotion and/or sale of tobacco products through electronic media such as websites and chat-rooms;

• end use of trademarks package designs that recall past tobacco product advertising and which undermine the effectiveness of current legislation banning tobacco promotions;

• protect young people from retail promotions of tobacco products at point-of-sale, and through purchase inducements, direct marketing and promotional personnel;

• reduce supply of cigarettes to children, including effective enforcement of legislation (with enforcement efforts covered by revenue from retail licence fees). Encourage governments to extend or develop legislation to mandate smoke-free workplaces public places, including outdoor areas such as restricted seating, near air-conditioning intakes and near doorways.

Encourage proposal development, media and/or direct lobbying with government and/or other potential funding bodies such as health insurance companies or

pharmaceutical companies with emphasis on the effectiveness and cost-effectiveness of these strategies. This should include long-term core funding of cessation services – based on sound behavioural principles and research – that are readily available to all smokers. Nicotine replacement products should become integrated into the range of cessation services and nicotine

replacement therapy subsidised where the user takes reasonable steps to maximise its effectiveness. Reduce commercial

inducements for uptake of smoking, particularly by children

Eliminate exposure to environmental tobacco smoke in the workplace and other public places. Provide free or low-cost smoking cessation services and products readily throughout Australia, particularly to those at most need.

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GOALS STRATEGIES

Encourage support for and promotion of state Quitlines and national Quit internet-based services.

Support measures to provide cessation assistance to people whose high smoking rates and extreme social disadvantage warrant special effort (e.g. Aboriginal and Torres Strait Islander people, unemployed and low-income people, people with psychiatric disabilities).

Adopt the inclusion of brief advice on cessation, appropriate referral to smoking cessation services and prescription of appropriate tobacco dependence therapy as standard care in clinical practice guidelines and work protocols of health professionals.

Lobby professional and disease-specific associations and organisations to develop evidence-based guidelines and clinical protocols that include advice to quit, appropriate referral to cessation services and prescription products for all health professionals.

Encourage the offering of tobacco dependence treatment to all patients who smoke who are admitted for acute health care, pre-natal outpatient care and birthing services, rehabilitation, psychiatric care and drug treatment.

Lobby government to include referral and follow-up of smokers to specialised tobacco dependence treatment services on the Medicare Schedule.

Establish a system to regulate the promotion and sale of all products that deliver nicotine in line with the

development of improved pharmacological aids to quitting. Liaise with government to engage in strategic negotiations with pharmaceutical companies to ensure that

deregulation of nicotine replacement therapy and other cessation products is accompanied by commitment to product innovation assistance to address broader tobacco control goals.

Support the routine provision of cessation advice,

counselling and support to complement pharmacological cessation aids to increase their efficacy.

Lobby governments to ensure that policy

measures to prevent tobacco use are included tobacco. Encourage the Federal government to include reduction of tobacco use as a priority in all relevant national health strategies.

Support the adoption of fiscal policies that ensure adequate state and territory funding for social

determinants of health relevant to smoking, including education, family support, recreation and welfare policies and mental health promotion.

Promote clinical cessation interventions.

Increase consumer access to improved nicotine replacement and other pharmacological aids to quitting.

Support broader health and social policies likely to reduce demand for in all federal and state drug policy strategies.

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The Heart Foundation is committed to advocacy action and partnerships to implement the recommendations in this policy paper.

References

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Facts 2001. AIHW Cat No. CVD 13. Canberra: AIHW, National Heart Foundation of Australia, National Stroke Foundation of Australia, 2001.

3. Hill D, White V, Letcher T. Tobacco use among Australian secondary students in 1996. Australian and New Zealand Journal of Public Health 1999;23(3):252–9.

4. Hill D, White V, Effendi Y. Changes in the use of tobacco among Australian secondary students: results of the 1999 prevalence study and comparisons with ealier years. Australian and New Zealand Journal of Public Health 2002;26(2):156–63.

5. Hirdes J, Maxwell M. Smoking cessation and quality of life outcomes among older adults in the Cambell survey on well-being. Canadian Journal of Public Health 1994;85:99–102.

6. Collins D, Lapsley H. The social costs of drug abuse in Australia in 1988 and 1992. National Drug Strategy Monograph series No 30. Canberra: Commonwealth Department of Human Services and Health, 1996.

7. WHO. World Health Organisation launches new directions for health into the 21st century. In: Press Release, World Health Report 1999. www.who.int/whr/1999/en/press-release.htm, 1999. 8. Peto R. Global tobacco mortality: monitoring the growing epidemic. In: 10th World Conference on

Tobacco or Health; 1997, Beijing; 1997.

9. Villablanca AC, McDonald JM, Rutledge JC. Smoking and cardiovascular disease. Clinics in Chest Medicine 2000;21(1):159–72.

10. US Department of Health and Human Services. The Health Consequences of Smoking: Cardiovascular Disease. A report of the Surgeon General. Rockville, Maryland: Public Health Service, Office on Smoking and Health, 1983.

11. Doll R. Tobacco: A medical history (a lecture). In: Anti-Cancer Council Victoria; 2000. 12. WHO. World Health Report 1999, 1999.

13. English D et al. The quantification of drug caused morbidity and mortality in Australia. 1995. Canberra: Commonwealth Department of Health and Human Services, 1995.

14. He J, Vupputuri S, Allen K, Prerost M, Hughes J, Whelton P. Passive smoking and the risk of coronary heart disease–a meta-analysis of epidemiologic studies. New England Journal of Medicine 1999;340(12):920–6.

15. Hankey G. Smoking and risk of stroke. Journal of Cardiovascular Risk 1999;6:207–11.

16. Glantz S, Parmley W. Even a Little Secondhand Smoke is Dangerous. Journal of the American Medical Association 2001;286(4):462–3.

17. Otsuka R, Watanabe H, Hirata K, Tokai K, Muro T, Yoshiyama M, et al. Acute Effects of Passive Smoking on the Coronary Circulation in Healthy Young Adults. Journal of the American Medical Association 2001;286(4):436–41.

18. NHMRC. The health effects of passive smoking: a scientific information paper. Canberra: National Health and Medical Research Council, 1997.

19. Winstanley M, Woodward S, Walker N. Tobacco in Australia: facts and issues (second edition). Melbourne: Victorian Smoking and Health Program, 1995.

20. US Department of Health and Human Services. Preventing tobacco use among young people. A report of the Surgeon General. Atlanta, Georgia: Public Health Service, Centers for Disease Control and Prevention, Office on Smoking and Health, 1994.

21. Gray N, Daube M (eds). Guidelines for smoking control (2nd edition), UICC Technical Report Series, Vol 52. Geneva: International Union Cancer Control (UICC), 1980.

22. US Department of Health and Human Services. Reducing Tobacco Use. A report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000. 23. Centers for Disease Control and Prevention. Best Practices for comprehensive tobacco control

programs – August 1999. Atlanta, Georgia: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1999.

24. Centers for Disease Control and Prevention. Strategies for reducing exposure to environmental tobacco smoke, increasing tobacco-use cessation, and reducing initiation in communities and

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health-care systems. A report on recommendations of the Task Force on Community Preventive Services. MMWR 2000;49(No. RR–12).

25. Pierce J, Gilpin E, Emery S, White M, Rosbrook B, Berry C. Has the California tobacco control program reduced smoking? Journal of the American Medical Association 1998;280(10):893–9. 26. Fichtenberg CM, Glantz SA. Association of the California Tobacco Control Program with declines

in cigarette consumption and mortality from heart disease. New England Journal of Medicine 2000;343(24):1772–7.

27. Lightwood J, Fleischmann K, Glantz S. Smoking Cessation in Heart Failure: It Is Never Too Late. Journal of the American College of Cardiology 2001;37(6):1683–4.

28. Hassard K (ed).National Tobacco Campaign – Evaluation Report Volume II. Canberra: Commonwealth of Australia, 2000.

29. Australian Institute of Health and Welfare (AIHW). Cardiovascular Health. A report on heart, stroke and vascular disease. National Health Priorities Areas Report. Canberra: AIHW, 1999.

30. National Expert Advisory Committee on Tobacco. National Tobacco Strategy 1999 to 2000–03: a framework for action. Canberra: Commonwealth Department of Health and Aged Care, 1999. 31. VicHealth Centre for Tobacco Control. Tobacco control: a blue chip investment in public health.

Melbourne: Anti-Cancer Council of Victoria, 2001.

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