Tobacco controlled – what will it take? Oceania Tobacco Control, Brisbane October 2011

1. Tobacco controlled – what will it take?Oceania Tobacco Control, Brisbane October 2011 Richard Edwards Department of Public Health, University of Otago, Wellington, New Zealand

2. Acknowledgements • Many, many colleagues who work on tobacco control related research • Particular thanks to: ASPIRE 2025 team + Julian Crane and Rob McGee Nick Wilson Anaru Waa Tony Blakely + Many others

3. Structure • What do we mean by tobacco controlled? • Achieving the vision • It is possible! • Some challenges • Some thoughts about the how? • Another (even bigger) challenge • Conclusions

4. Endgame as a goal • Zero (or very close to) smoking/tobacco use prevalence/consumption (Finland, NZ Govt) • No/minimal supply of tobacco (Bhutan, NZ govt) • Zero or close to zero uptake of tobacco (NZ Tupeka Kore Vision) • Zero or close to zero tobacco related mortality and morbidity (US Department of Health and Human Services) • A society in which tobacco use is fully denormalised • A society in which children are fully protected from tobacco (NZ Tupeka Kore Vision) NB Equity issues – ‘….for all social and ethnic groups’.

5. Endgame as a philosophy • Rejection of the status quo: • i.e. gradual decline in use and prevalence and incremental policy advances • Radical solutions to address an unacceptable situation • Aims to achieve endgame goals quickly = PARADIGM SHIFT

6. Percentage smoking by ethnicity, 1991-2007 Source: Statistics New Zealand; ACNielsen (NZ) Ltd, reported in Tobacco Trends 2007

7. Endgame as a philosophy • Rejection of the status quo: • i.e. gradual decline in use and prevalence and incremental policy advances • Radical solutions to address an unacceptable situation • Aims to achieve endgame goals quickly = PARADIGM SHIFT

8. Endgame as a process • Having an explicit government intention and plan to achieve close to zero prevalence of tobacco use. • A clearly stated government ‘end’ target date within a maximum of two decades. Thompson et al. Tobacco Control (in press)

9. Endgame as a strategy A deliberate planned strategy of interventions to achieve endgame goals for tobacco use e.g. • Combinations of established (e.g. price, mass media) and new (e.g. plain packs, supply restrictions) tobacco control interventions • Over-arching intervention strategies e.g. sinking lid, regulated market model

10. Structure • What do we mean by tobacco controlled? • Achieving the vision • It is possible! • Some challenges • Some thoughts about the how? • Another (even bigger) challenge • Conclusions

11. Successful endgame solutions • CFCs • Leaded petrol • Asbestos • Infectious disease eradication (smallpox etc)

12. Population support for the endgame Support for an end of tobacco sales within 10 years Source: HSC 2008 Health and Lifestyles Survey Thomson et al. N Z Med J. 2010;123(1308):106-111.

13. Smoker support for the endgame Source: Edwards et al NZ Med J 2009

14. Daring to Dream: vision is compelling Participants in daring to dream were presented with a vision of a tobacco free future where children were protected from seeing smoking as a normal behaviour, had virtually no access to tobacco and hence minimal risk of becoming smokers and being exposed to tobacco smoke. “I think the vision is very good because it …, it makes you stop as a parent and a grandparent and think what the hell are we doing for our kids” – Policy official Edwards et al. BMC Public Health 2011, 11:580

15. Young smoker responses to Smokefree 2025 goal “This is awesome…This makes me feel really proud to be a New Zealander” “.. it would be something that would be amazing, but I don’t know how possible it would be.” “I reckon it’s pretty cool. I don’t want to be a smoker in fifteen years.” “I’ll be really pissed off when they make it smokefree and I can’t buy cigarettes any more. At least for the first two weeks .. but in the long run, I think smoking is something our country can do without.” “2025 ….[pause] am I allowed to swear? [laughs] in your fucking dreams.” Hoek, Maubach et al. Unpublished data.

16. Smoking among doctors and nurses (NZ), 1976-2006 Edwards et al NZMJ 2008; 12: 43-51

17. Some other occupations (NZ)

18. Structure • What do we mean by tobacco controlled? • Achieving the vision • It is possible! • Some challenges • Some thoughts about the how? • Means and ends • Another (even bigger) challenge • Conclusions

19. Challenges • The numbers game - need for mass cessation quickly • Continuing disparities in smoking • Shifting patterns of smoking uptake • New beliefs, behaviours and influences • Lack of ‘proof’ for policy and population-based approaches • Tobacco industry

20. Interplay of cessation and uptake changes Source: Gartner et al. Tobacco Control 2009; 18: 183-189.

21. Challenges • Need for mass cessation quickly • Continuing disparities in smoking • Shifting patterns of smoking uptake • New beliefs, behaviours and influences • Lack of ‘proof’ for policy and population-based approaches • Tobacco industry

22. Adult smoking by ethnic group (NZ)

23. Adult smoking by deprivation (Census 2006 data, Ponniah et al NZ Med J)

24. Disparities in smoking by occupation: NZ 2006 census

25. Challenges • Need for mass cessation quickly • Continuing disparities in smoking • Shifting patterns of smoking uptake • New beliefs, behaviours and influences • Lack of ‘proof’ for policy and population-based approaches • Tobacco industry

26. Regular smoking by Year 10 female students, 1999-2010 (NZ) Source: ASH NZ. National Year 10 ASH Snapshot Survey, 1999-2010

27. Prevalence of current/regular smokers (%), by age group: Census 2006 compared with NZTUS 2006 Source: Statistics New Zealand; NZTUS 2006

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29. Shifting uptake results in new challenges Challenges of preventing uptake in young adults • Lack of research on preventive interventions • Dispersed settings and social networks (c.f. school) • Increased autonomy • New beliefs about smoking and smoking –related behaviours and determinants • Legality of purchase and use (different ethical and moral framework to justify interventions)

30. Challenges • Need for mass cessation quickly • Continuing disparities in smoking • Shifting patterns of smoking uptake • New beliefs, behaviours and influences • Lack of ‘proof’ for policy and population-based approaches • Tobacco industry

31. New smoking beliefs and behaviours – social smokers ‘I smoke but I am not a smoker’: Phantom smokers (Choi et al. J Am Coll Health 2010: 59: 117-125) • survey of 899 US students (17-25 years). 15.6% identified as smokers but 45% smoked

32. New smoking beliefs and behaviours – social smokers (2) Social smokers differentiate themselves from ‘addicted smokers’: “I’ve never actually had a cigarette when I I’m just by myself … so I don’t see myself as a smoker, but I see myself as a social smoker … they’re almost mutually exclusive.” Hoek ,J et al (under review, Tobacco Control) “Well I actually gave up..in October last year. So I haven’t had a smoke for almost [hesitation] ...I’ve had the odd smoke but I haven’t been a fulltime smoker for almost 12 months ...I might have like one a fortnight, or if I’m having a drink and it’s been a stressful day then I’ll have one but..if I um..if I feel I need one I’ll have one, but other than that I don’t (be)cause I’ve beaten the addiction.” Ferry, B. Draft MPH dissertation.

33. New smoking influences – late uptake smokers “Yip and that’s where I started cause my work mate smoked. Oh he was always offering me one so yeah ...Oh it just gradually built up (laughs). Say we’re doing jobs together and he’d offer me a..and I’d say na..oh the first couple of times..and he’d say..he’d keep on offering and I said ‘why not?’ ..and then..yeah” ‘Peter’ “Oh it was quite horrible really when I think back. Um we were all smokers, we all smoked inside....that’s just what we did...it was a student flat, .. it was a horrible house so we just didn’t really care. ..it was easy to get home and sit down to start with and they’re smoking so you’re like ‘Oh well I might as well have one.’ ” ‘Michelle’ Ferry, B. Draft MPH dissertation.

34. New smoking behaviours – the role of alcohol NZ ITC study: % Hazardous drinking (AUDIT >=8) All smokers 33.1% 18-24yrs smokers 59.0% Māori smokers 42.1% Pacific smokers 52.1% All participants in NZHS – 13.1% Wilson et al. In press NZMJ.

35. New smoking behaviours – the role of alcohol (2) Social smokers often only smoke when drinking: “When I’m drunk, I guess … the care factor goes down … goes down to zero … like who cares about smoking?” “I just don’t have any cravings unless … I’m out having a few drinks and then I do feel like one…” “… some nights I can smoke 14 or 15 ciggies or a pack while I am drinking, but I can never do that without alcohol”. Hoek et al (under review, Tobacco Control) “I can smoke a whole packet in one night drinking and not have to smoke for two or three days afterwards ….. Yeah I think it’s just social smoking … I think heaps of people are like that…” (Māori female) “ Well there’s smoke and there’s drink … They’re husband and wife aye.“(19 year old Pacific man) Glover et al. WhyKwit. Auckland University, 2010

36. New smoking behaviours – the role of alcohol (3) Drinking undermines quitting: “That’s the other thing. You quit and then you drink. You’re used to the habit of having a smoke when you drink. Even when you’re not smoking it goes hand in hand….Oh, a smoke when you drink – just to kick in the buzz.” Pacific Male smoker Glover et al. WhyKwit. Auckland University, 2010

37. The role of alcohol – experimental evidence • Diary study with 74 smokers – alcohol use predicted smoking and was associated with urges to smoke and getting a ‘rush’ from smoking. Piasecki et al Psych Add Behav 2008; 22: 230-239. • Expectation of alcohol increased positive effects of smoking (satisfaction, calming, taste) and administration of alcohol increased smoking and reduced nausea from smoking among 19 young adult experimental smokers. McKee et al. Psychopharmacology 2010; 210: 355-364.

38. New smoking behaviours – challenges for tobacco control • Health education and cessation messages may be ignored by social smokers who do not identify as smokers • Young adults may respond to different smokefree messaging (and media) • New interventions needed in settings where smoking occurs: college, workplace, bars etc • Establishing new social norms about unacceptability of offering cigarettes to new smokers and quitters • Interventions may be undermined by alcohol and co-intervention may be required

39. Challenges • Need for mass cessation quickly • Continuing disparities in smoking • Shifting patterns of smoking uptake • New behaviours and influences • Lack of ‘proof’ for policy and population-based approaches • Tobacco industry

40. Lack of ‘proof’ for policy and population-based approaches • Where’s the evidence? – frequent argument of tobacco control opponents and policy-makers • Evidence-base is often limited and difficult to ‘prove’ impact of policy interventions

41. Evidence base – point of sale Peer-reviewed evidence (2009): • Observational studies, most cross-sectional, ? generalisable • Experimental studies limited e.g. exposure and setting, outcome measures, generalisability etc • Self-reports in surveys and qualitative studies – limited by possible social desirability etc biases • No published evidence from jurisdictions with PoS bans

42. Why the lack of evidence? • Lack of priority and funding for evaluation • Methodological difficulties e.g. • Lack of comparison groups • Lack of control over intervention implementation • Confounding interventions and influences • Lack of data to assess prior trends and long-term outcomes • Novel interventions

43. Challenges • Need for mass cessation quickly • Continuing disparities in smoking • Shifting patterns of smoking uptake • New behaviours and influences • Lack of ‘proof’ for policy and population-based approaches • Tobacco industry

44. Tobacco industry • Arguments • Interventions don’t work (lack of evidence) • Interventions infringe personal liberty (freedom to choose, nanny state, slippery slope, commercial freedom, legal product etc etc) • Interventions will have disastrous economic and other unintended effects • Tactics • Legal challenge, PR and advocacy, lobbying, trade agreements, funds for research and ‘science’ etc etc • Continued marketing • Promotion, price, product (modification), place/accessibility,

45. “… the primary health argument has been lost. There is no way any feasible case can be argued in medical terms….The only way that the right to smoke can be defended is to link it up with the freedom of lifestyle position and with the broader libertarian critique of “health fascism” and the paternalism and authoritarianism of the medical establishment… We have to shift the focus of the debate from the enemy’s strong ground – health – to our strong ground – freedom of choice and individual liberty.” From Forest’s future strategy: A discussion. Chris Tame, 1989.

46. Framing the discourse: portray tobacco control advocates and policies as authoritarian

49. Framing: association of smoking with female emancipation

50. Link tobacco products with cataclysmic and iconic events: Fall of the Berlin wall A boy with a West-West shirt on distributes packs of cigarettes to a East German motorcyclist at the West German checkpoint Helmstedt, Nov. 10, 1989. “Test the West”