Is it time to call the endgame for tobacco in Australia?

Gretchen: Hello there, listeners, and welcome to Prevention Works. And it’s an exciting concept and hopefully an imminent reality we’re discussing in some detail today, and that’s the beginning of the end for tobacco in Australia. New Zealand will legislate this year to gradually raise the age of cigarette purchasing such that retailers will not be able to legally sell tobacco to anyone born in or after the year 2010, and with me on the line from Brisbane, with the sound of cicadas humming away in the background, is Professor Coral Gartner from the University of Queensland’s School of Public Health. Professor Gartner is an international expert in tobacco control policy, and the director of the NHMRC Centre of Research Excellence on Achieving the Tobacco Endgame, otherwise known as Tobacco Endgame CRE. And the Tobacco Endgame CRE works closely with the Prevention Centre through our Collaboration for Enhanced Research Impact, which brings together preventative research organisations to develop aligned information for policy and practice. Tobacco Endgame CRE has been working for a year, reviewing international policies, kickstarting research projects, and preparing to make proposals for Australian policy and processes, which we might follow to reduce even further the hold the tobacco industry has on Australia.

Welcome to you Coral, and thanks for joining us on Prevention Works. And I have to say it does feel a little bit wonderful to imagine that practice that was so ubiquitous in my childhood, and early workplaces even, might be coming to its last here in Australia. How long have you personally been working towards this?

Coral: Right, so I started in this field of tobacco control policy in 2006, that was following completion of my PhD in Public Health, and that project that I first started on was looking at the future of tobacco control in Australia, and I’ve basically just continued on from there looking at the new policies that are over the horizon and what we could do to, as you say, end the cigarette epidemic in Australia so that it’s no longer a leading cause of preventable death.

Gretchen: So, what is it that’s contributed to tobacco’s protected status in this country, is it culture, why has tobacco been so hard to kick in terms of our public health strategies?

Coral: Yeah, look, I think this really goes back to the history of tobacco control. So yeah, when the harms of tobacco smoking first became well known through some landmark studies, such as the British Doctor’s study, where they found that half of all long-term smokers were dying from a tobacco-related disease, they had the opportunity there that they could have really brought in some stronger policies and mandated a phase out of commercial tobacco products. But they didn’t do that, they instead took a more incremental approach, and I think some of the assumption was that people would just stop smoking when they had heard about the great harms that came from smoking. Unfortunately, this also overlooked the fact that tobacco smoking is incredibly addictive, and back when they first found out about the harms of smoking, they didn’t really fully appreciate how addictive nicotine delivered by a cigarette really is. So, the pressure from the tobacco industry opposing strong controls and the pressure that they put on politicians, and I guess also politicians also concerned about people who smoke not being ready to quit may have also played a really strong influence here in delaying taking strong action on tobacco.

Gretchen: So, let’s get to Tobacco Endgame, the Centre of Research Excellence. What are the basic points of the process of eliminating tobacco from the socio-cultural context in which it currently inhabits, that Tobacco Endgame CRE has come up with?

Coral: Right, so there has been a lot of work done in tobacco control to reduce the use of smoking over the years in countries like Australia, so Australia has been very successful, but it really has taken a very long time to get down to around that 10 per cent level.

Gretchen: Ten per cent of the adult population are smokers, you mean?

Coral: Yes, so it’s actually more than that, it’s closer to 15 per cent of adults who smoke regularly, but we’re heading down towards that 10 per cent level of people who smoke every day, but that’s still a lot of people who are dying early of a preventable disease. And one of the problems with tobacco smoking is, of course, you take it up when you’re young, you don’t take it up in adulthood when you know better and you can see how harmful it is and appreciate how difficult it might be to quit. So one of the things that we’re hoping to do is to change the environment that we have in Australia to make it less likely that young people will experiment with smoking and become daily users of tobacco products. But we also need to focus on adults, so research I have done with modelling the impact of quitting versus the impact of preventing uptake, has clearly shown that for us to make a big dent in the smoking prevalence, we really do need to increase the percentage of people who quit smoking every year.

So, the National Preventative Health Strategy which was released by the government just a couple of weeks ago (November 2021) set out some goals to achieve a healthier population by the year 2030, and within that they set a goal of reducing smoking prevalence to less than 5 per cent.

Gretchen: But how is that going to change? I mean Australia has been trying to help people quit smoking for a long time. Even if you’re a non-smoker, you’re very aware of the Quitline and all that kind of thing, what could possibly change to make that quitting even easier or more appealing?

Coral: Yes, so our centre is looking at a number of strategies. One of these is reducing the availability of cigarettes. We know that when people are trying to quit smoking, they get cravings for it and so if you’re feeling a bit vulnerable while you’re making a quit attempt, it’s very difficult to avoid being able to purchase cigarettes very easily because they are so ubiquitous. Your major supermarket players like Woolworths and Coles, they all sell cigarettes, you’ve got every petrol station selling cigarettes, you’ve got convenience stores, so they’re really there every time you go into a retail environment, that product is there waiting or you, it was just that it was moment of being tempted to purchase it when it really wasn’t what you wanted to do. So, reducing the availability of cigarettes is one strategy that we are looking at. Another strategy that’s been discussed, and is looking like it’s going to be implemented in New Zealand, is reducing the nicotine content of cigarettes to trace levels. Currently most cigarettes have about 15 to 16 milligrams of nicotine per gram of tobacco in it, and this policy would reduce that by around 98 per cent, so down to around 0.4 milligrams of nicotine per gram of tobacco. So, what that policy would do would be to not necessarily take cigarettes off the market, but the cigarettes that were available to purchase would not be addictive or they would be very minimally addictive.

Gretchen: So, what this process marks is a shift in emphasis right, from consumer responsibility or an individual responsibility to the retailer, from demand to supply. Why does that matter so much and how could this make such a dramatic difference?

Coral: Look, I think changing the context that we live in is a really vital and critical part of achieving a tobacco endgame, because the current situation, even though people have been given a lot of education about the harms of smoking, that hasn’t been reflected in the availability of these products. So, for example, you can’t go into a store and purchase heroin, cocaine, lots of different products that are addictive and harmful, because they are addictive and harmful, there are other products that seem to have a health benefit, so morphine, codeine, and so on, but they’re given a very strong regulatory framework in which you, again, it’s not up to the consumer to go and purchase that product just because they want to use it, but they do have to go and get a health professional as a gatekeeper to those products. So, changing that context again where the person is not just buying the cigarette as a normal consumer product, but where they may get some advice about why it’s harmful, and what other products there are that they could use and offer to quit, would be a very big change in the way that tobacco is available. But you often hear people say, ‘Well, if it’s so harmful why doesn’t the government just ban it’, and so it’s that widespread retail availability that also conveys a message to people that it can’t be really that important, it can’t be that dangerous if you can buy it in the supermarket.

Gretchen: And what’s really interesting about that, as you said earlier, is that in fact most people don’t want to smoke, so the message has gotten through that this is harmful and dangerous and not great for you, but it’s the addiction that’s the issue now.

Coral: That’s correct, and that’s why also we’re looking at a range of these policies, so the New Zealand Smoke Free Action Plan that was released a few weeks ago is a great example of the combination of policies that we should probably be looking at here as well. They are also looking at reducing the number of retailers that could supply tobacco products, they’re talking about a 95 per cent reduction in retail availability, so that would reduce the number of retailers who can sell tobacco from around 8,000 in that country down to around 400. So that would be a big change in the context of how you could obtain cigarettes. Also, as I mentioned, they are talking about bringing in this very low nicotine content standard and I think that would be a very dramatic impact on addiction to cigarettes in that country. Also, they’ve announced a tobacco-free generation policy, and that is where they will make it illegal to supply tobacco products, well, I should say cigarette products, to people who are born after a certain year, so I think they’ve set it at people who are aged 14, apparently, so everyone who is born after that, everyone who is 14 now and younger will not be able to purchase cigarettes into the future.

Gretchen: So, are you saying that your and New Zealand’s proposals are very much in lockstep. Would you have liked it to be Australia to lead the way, as we have in so many other prevention measures?

Coral: Well, it would always be great to see your country being the leader in this, but I think it’s just fantastic that another country is going ahead, just having a country that is brave enough to start implementing these new policies, and actually thinking in terms of how long they want this product to be commercially available in their country, is just a fantastic outcome. I guess we’ve got the opportunity here that we could learn from New Zealand, but hopefully that we can also join them in some of these policies. I do think that we probably need to look at how we would implement them in this country, it may be a little bit different to how it’s going to be implemented in New Zealand, and we may have a slightly different mix of policies, so we may not follow exactly, but it would be great if we also developed a clear strategy for how we’re going to get to that very low smoking prevalence that has been announced.

Gretchen: And with very definite timelines. So are you working, are you both drawing from the same sort of sources, because it sounds very much like they’re doing what you would propose that Australia does, how did that correlation develop?

Coral: Yes, so this conversation, I guess, about the tobacco endgame, has been going for a number of years now, and in a global context. So, there are researchers in New Zealand that have actually shown a lot of leadership in this area, and they’ve been researching these polices for many years now, so New Zealand really has been a leader in this space for many, many years now. So when we set up, when I set up the CRE, I invited some of these New Zealand colleagues onto the team, so they also are part of our Centre of Research Excellence, and they make a great contribution to our thinking, but also we have colleagues in Canada as well, and we are part of that wider global discussion of tobacco endgame policy, so I think we can learn from lots of different countries in terms of what policies are available that we should be considering, and also how they’re implemented. So it’s one thing to have a policy, maybe make a law and implement it, but if you don’t do it in a way that is enforceable or that supports people to quit smoking, then it’s not going to be a success, and again I think one of the wonderful things about the New Zealand approach is that it’s not just one policy that they’ve selected, and it’s all underpinned with support for people to quit smoking, and they’re increasing the amount of support that will be available to help people quit smoking, and particularly looking at those populations that have high smoking prevalence, so people with mental health disorders and so on.

Gretchen: Yeah, so I was going to ask you about them and we might get to those in a moment, can we talk a little bit about what’s happening overseas, I mean I understand that the Netherlands has legislated for supermarkets to stop cigarettes from 2024, and even the Philippines, which I imagine, well there’s one city council in the Philippines wants to end tobacco sales too, and even in the US, district by district, there appears to be a phasing out of commercial tobacco sales.

Coral: That’s correct, and I think that looking internationally also gives us a good view of how this might be implemented in different jurisdictions, so, for example, Balanga City Council in the Philippines was actually one of the early jurisdictions to implement the Tobacco Free Generation law, as well as a complete sales ban on tobacco products. So that was implemented within a university town area, so I guess that was a big focus there on protecting young people at the time when they’re often taking up smoking. So that policy, I guess, has already been implemented and in place for a number of years now. There was a challenge against that by the tobacco industry, and I believe that that court action may be still ongoing, but we’ll have to see how that turns out.

Gretchen: And are you expecting the tobacco industry to push back in Australia?

Coral: Yeah, so that’s been the history, they often use legal action as a way of ‘regulatory chill’, they call it.

Gretchen: Right.

Coral: So they try to scare off other places too from implementing strategies, so even when they don’t have a particularly strong legal position they will still take legal action, because countries will still have to expend money to defend their policies, but what we’ve seen there is that if a country stands up and defends their policies, and particularly if they’ve designed those policies to be legally defensible, then they can succeed against these powerful companies, and then those policies will then be disseminated throughout the globe because we’ve seen many, many countries take up that plain packaging policy after Australia won that legal action in the international courts.

Gretchen: Yeah, but you also might get push back from small retailers, how does the argument of their right to make a living from tobacco play into your proposals?

Coral: This is something that is a really important aspect of how we would implement some of these policies. So, we need to take a step back and think about that issue of businesses relying on tobacco sales and what that means. So if your business is relying on tobacco then that contradicts or that’s in direct conflict with the goals of the government to reduce smoking down to very low prevalence, like less than five per cent or even lower, and it relies on people not quitting smoking, it relies on new people taking up smoking, and so it continues that awful cycle of people using this product, becoming addicted, and then dying from a tobacco-related disease many years earlier than they would have if they hadn’t have taken up smoking.

Gretchen: And it’s not like this hasn’t been kind of on the cards for quite some time. If we’re at the point where we’re starting to think of policy, how might policymakers ensure that retailers are motivated to make these changes?

Coral: Well, I think firstly, communicating with retailers is vital, and letting them know that look, this is inevitable, because smoking prevalence is going down, so regardless of whether the government actually mandated that tobacco retailing ended or was made very difficult for people to retail tobacco, there are going to be fewer people who are purchasing that product in the future, if the government is successful in reducing smoking by whatever policies they implement. So, tobacco retailers need to already have that on their radar. Another thing we need to keep in mind is that, when people stop smoking, they don’t just stop spending their money, so they will go and purchase other products. So, it’s not that that money that they were making from tobacco sales disappears, they can encourage people to buy other products or services. Now I think that’s part of the problem, is sometimes it’s difficult for businesses to think five years or so ahead, unless actually given a date by which they need to be working towards, so setting some dates and some guidelines would be very helpful, I believe, to these small businesses to be thinking in terms of okay, we do need to start acting on this and start planning ahead, rather than just that slow decline in tobacco sales that’s going to happen anyway.

Gretchen: I’m wondering if this is a big shift in thinking for Australian legislators and what the political appetite is for tobacco endgame in Australia?

Coral: Yeah, so I believe that all governments want Australians to be as healthy as they can. It’s a goal of all governments that we maximise life expectancy, that we maximise people’s wellbeing and opportunity to contribute to the economy, so we do need to also consider that tobacco use has a big impact on productivity, because people die early, they’re sick for longer, they can’t contribute as meaningfully to the economy as if they were at their best health, so it’s also got that economic imperative too. But I think if we, again, take a step back and think about well, the majority of people in Australia don’t smoke, and many of the people who do smoke don’t want to continue smoking, it’s just that it’s that environment that sustains them and the difficulty that they’ve experienced in quitting. So the percentage of people who currently smoke and are happy to smoke and want to continue smoking into the long term, is actually quite small, and so that small percentage of people could probably be accommodated through other supply options. We don’t necessarily have to have a complete ban, it may be that there’s some restricted supply, we don’t need to make tobacco an illicit product. And that’s what we’re discussing with our centre is options that fall short of prohibition, so other options there that might be more appropriate for the level of harm that tobacco causes, but don’t necessarily make it an illicit product and don’t make it illegal to use that product.

Gretchen: So, there’s two other groups that I’d like to talk about as we come towards the end of our conversation, that is those with an established habit, as you mentioned before, especially those with mental health issues, because we know that smoking is high in that group and very, very hard to kick, but also the rise in vaping and e-cigarettes.

Coral: Yeah, so particularly those populations with high smoking prevalence, such as people with mental health conditions, we do know that we need to focus a lot more on providing them with appropriate support to quit smoking. So it’s also these policies will also assist those populations who are currently encouraged to keep smoking just through the widespread availability, and that pervasiveness of cigarette smoking, as well as protecting young people who are experiencing mental health disorder for the first time from being exposed to a high smoking-prevalence environment. But also we know that from research that people with mental health disorders also want to quit smoking, and so a lot of the time it’s that they’re not given as much support, sometimes the assumption is that they don’t want to quit or that they can’t quit, whereas it’s just that they haven’t been provided that supportive environment as well as extra assistance to quit. We know that the same policies and interventions that help other people to quit smoking also work amongst people with mental health disorders, but they may need extra support, so they may need a longer treatment program, that may need extra counselling sessions and so on. I think there just has been a real under-investment in that population in terms of helping them to quit smoking.

Now your other question was about vaping. Now this is a really controversial topic and there are different views, both within our research centre and just more broadly within the tobacco control community about what the role of vaping is within a tobacco endgame. There’s one view that we should just try to eliminate all forms of nicotine use, and there’s another view that nicotine products lie on a spectrum of harmfulness and what we should be doing is working through that spectrum and eliminating the most harmful products first and focusing on those, and that lower risk products may have a role to play there, particularly for some populations who have a very strong addiction to nicotine, and that having a substitute product may help.

So, in New Zealand they have changed their policy over the years on nicotine vaping products, they used to not be allowed to sell vaping products that contain nicotine in that country, and they’ve changed that to allow domestic sales now, and so there has been an uptake of nicotine vaping products, and we’ve also seen a decrease in smoking. So, there’s still research going on about the exact relationship between those two, but it is likely that having those products available has assisted a number of people to quit smoking. And having that alternative product available which has got that consumer acceptability, has likely assisted with introducing the stronger proposal of eliminating cigarettes from the market there. So that’s where also a less harmful alternative may have a role to play in terms of public acceptability if people feel that there’s another option for them to go to if they want to continue using nicotine.

Gretchen: And I suppose that you would see a repeat in the gradual diminishing of the quantity of nicotine in those products, as you are considering with cigarettes?

Coral: Well, that could be an option in the future, so people who are looking at this as a substitute product are often thinking that you would allow the nicotine to continue, at least for some time, in the alternative product so that people have got an alternative source. This was also proposed in the United States a few years ago, they talked about allowing people who are adults who are currently smoking to move to a lower-risk product that’s got that consumer acceptability, but at the same time they were also considering removing nicotine from cigarettes. So, it was seen as being a more balanced approach in that it wasn’t just forcing people to go cold turkey, per se, but having that alternative source of nicotine that could be delivered at a similar sort of rate as cigarettes.

The controversy around that, of course, is that products that are likely to be a very good replacement for cigarettes are also going to be addictive and may also have that attractiveness to young people too. So, finding that balance of providing people who smoke, who are adults, an alternative to move to, as well as protecting young people from taking up these products, which aren’t risk free but they are, we believe, quite lower risk compared to smoking, because when we look at the toxicology, people who vape have lower levels of the harmful chemicals, they’re excreting much lower levels of these harmful chemicals, than people who smoke. So, we know that they’re getting exposed to lower levels of toxins. As I said, it’s not risk free, it’s not something that is good for non-smokers to take up and there’s likely to be some deaths in the future, and so on, from people taking up vaping and continuing with that behaviour. So, this is, I guess, the conundrum here, how do you provide that support to people who are adults and who are smoking, and maybe can’t quit with the current methods, maybe they’ve already tried to quit, and haven’t been successful, and we know that from trials that these e-cigarettes or other vaping products can be a successful aid for some people, with how do we also protect young people, so I think this is around again the supply and how we supply them.

So, the Australian government also recently changed the way that nicotine products could be accessed in Australia, so they are allowing some access, it’s quite tight access because you do need to have a prescription from your medical practitioner. So, the policy is designed to avoid that young people taking up vaping. Again, how that is implemented and enforced I guess is whether that’s going to be successful or not, the fact that it’s been implemented without also reducing the access to cigarettes I think is going to limit the effectiveness of that as a substitute, so again, it’s that balance. Now we’ve seen New Zealand go the other way where they’ve allowed wide availability of nicotine vaping products as a consumer product. So I guess we can, we’ve got this, I guess interesting natural experiment set up in a way between our two countries here, that we’ve got one country that’s allowing the product to be sold as a consumer good, and eventually will be, once they bring in these restrictions on the supply of cigarettes, will be wider available than cigarettes, whereas in Australia we haven’t actually announced a specific policy on reducing availability.

Gretchen: In terms of the work for the Tobacco Endgame CRE, I’m really interested in the name, right, it’s a very clear message, and you started the research centre, why did you choose Tobacco Endgame as a, it’s not as muted as you might imagine a title, it’s pretty direct?

Coral: Yeah, so this is I guess a term that’s been used in the tobacco control field for a little while thinking about these strategies that could really reduce smoking down to very low prevalence, and I guess it appeals to me in terms of thinking about okay, so where do we want to go with this, what’s the end of this, is it just to continually keep trying to suppress tobacco smoking with new policies, new media campaigns, and so on, or is it actually thinking about how long should this product, which is incredibly harmful and addictive, be available as a commercial product that anyone can sell to anyone over the age of 18. To me, it’s more thinking about where does this end, and how do we get there, and what is an appropriate long-term supply option for a product like this?

Gretchen: Where and when does this end? I think that’s a really great place to leave our conversation and thank you very much Professor Coral Gartner for joining us here on Prevention Works. And I wanted to let you know you’ll find more information on our website and in our show notes, including a link to our resource hub, the Value of Prevention  evidence review, which amongst other things demonstrates the virtuous circle impacts of banning tobacco for the nation’s health. I’m Gretchen Miller, see you next time.