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

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 Hoek, Maubach et al. Unpublished data. I reckon its pretty cool. I dont want to be a smoker in fifteen years... it would be something that would be amazing, but I dont know how possible it would be. 2025 ….[pause] am I allowed to swear? [laughs] in your fucking dreams. Ill be really pissed off when they make it smokefree and I cant 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.

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

17. Some other occupations (NZ) Occupation2006 Prevalence (1981 Census) Dieticians 3.1% (21.2%) Secondary teachers7.6% (17.2%) Ministers of religion2.7% (8.9%) Mathematicians and statisticians4.1% (12%) Dentists5.1% (18%)

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 Doctors 3.6%Hospital orderlies 27.6% Nurses 14.2%Nurse aides 23.5% Secondary teachers 7.6% Teacher aides 19.5% Kōhanga Reo teachers 41.2%

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

28. 28

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: Ive never actually had a cigarette when I Im just by myself … so I dont see myself as a smoker, but I see myself as a social smoker … theyre almost mutually exclusive. Hoek,J et al (under review, Tobacco Control) Well I actually gave up..in October last year. So I havent had a smoke for almost [hesitation]...Ive had the odd smoke but I havent been a fulltime smoker for almost 12 months...I might have like one a fortnight, or if Im having a drink and its been a stressful day then Ill have one but..if I um..if I feel I need one Ill have one, but other than that I dont (be)cause Ive beaten the addiction. Ferry, B. Draft MPH dissertation.

33. New smoking influences – late uptake smokers Yip and thats 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 were doing jobs together and hed offer me a..and Id say na..oh the first couple of times..and hed say..hed 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....thats just what we did...it was a student flat,.. it was a horrible house so we just didnt really care...it was easy to get home and sit down to start with and theyre smoking so youre 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 smokers33.1% 18-24yrs smokers59.0% Māori smokers42.1% Pacific smokers52.1% Wilson et al. In press NZMJ. All participants in NZHS – 13.1%

35. New smoking behaviours – the role of alcohol (2) Social smokers often only smoke when drinking: When Im drunk, I guess … the care factor goes down … goes down to zero … like who cares about smoking? I just dont have any cravings unless … Im 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 its just social smoking … I think heaps of people are like that… (Māori female) Well theres smoke and theres drink … Theyre 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: Thats the other thing. You quit and then you drink. Youre used to the habit of having a smoke when you drink. Even when youre 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 Wheres 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. Arguments Interventions dont 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. Introducing HPP … 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 enemys strong ground – health – to our strong ground – freedom of choice and individual liberty. From Forests future strategy: A discussion. Chris Tame, 1989.

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

47. Introducing HPP

49. Framing: association of smoking with female emancipation

50. Link tobacco products with cataclysmic and iconic events: Fall of the Berlin wall Test the West 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.

51. 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

52. Some thoughts about the how? Population vs individual cessation approaches Which methods? Some building blocks for success

53. Non- smokers Smokers Quit attempts Initial success Assisted Unassisted Long term success Individual cessation approaches Relapse

54. Non- smokers Smokers Quit attempts Initial success Assisted Unassisted Relapse Population-based approaches Price Mass media Marketing controls Product modification Cessation availability Accessibility Smokefree policies

55. Population approaches vs individual cessation Modelling study of impact on US smoking prevalence (2020): Current 19.8% Doubling quit attempts 13.9% Doubling treatment effectiveness15.9% Doubling treatment use16.7% Levy et al. AJPH 2010, 100: 1253-1259.

56. Impacts on population quit rates in New Zealand Population quit rate (%) % increase in quit rate Baseline1.950 Quit attempt rate2.1510 Proportion assisted1.991.8 Assisted RR2.023.6 Unassisted success2.1510 Relapse2.139.2 Impact of 10% relative change in each parameter Formula from : Tobias et al. AJPH 100: 1274-1281.

57. Some thoughts about the how? Population vs individual cessation approaches Which methods? Some building blocks for success

58. What methods? Price/tax increase (duty free) Mass media (campaigns, GHWs etc) Cessation support (treatments, availability etc) Tobacco marketing controls (plain packs, PoS etc) Smokefree policies (bars, cars, outdoors, etc) Product labelling and modification Reducing accessibility/supply (e.g. retail sector, smuggling) Etc

59. Five points about methods Intensification is essential Individual smoking cessation support vs population based measures Evidence-based as possible Focus on methods for high prevalence groups Consider additional strategies

60. Priority areas for new research and testing interventions Retail interventions (beyond PoS and minor access) Product labelling and modification Mandated additive disclosure Harm reduction approaches (safer cigarette) Nicotine reduction Additive removal

61. Possible retail interventions Sales to minors Sales/use ban, education of retailers, test purchases, public education Sales staff > 18 years, > 18 years only customers in tobacco shops Marketing and counter marketing Warning signs Ban PoS displays and ads Licensing Mandatory license lost if conditions breached +/- Fees/auctions for licenses(or incentives not to stock tobacco) +/- Community control +/- Restrictions on numbers/density/moratorium on new licenses Accessibility Restrict number/density of outlets e.g min distance between outlets, max density, opening hours Restrict proximity (e.g. to schools) Restrict type of venue/retailers (e.g. no events where >xx% underage, no venues where alcohol sold/consumed, specialist tobacconists only, no mobile sales) Others Mandate NRT etc sales + cessation support info available Mandate provision of sales data, tobacco industry communications Government retail monopolies Minimum price controls Max purchase per day License smokers

62. Population support for retail interventions Source: HSC 2008 Health and Lifestyles Survey Thomson et al. N Z Med J. 2010;123(1308):106-111. 66% agree, 20% disagree with reducing number of retailers that can sell tobacco

63. Smoker support for retailer restrictions Agree or strongly agree that tobacco products should only be sold in special places where children are not allowed to go: Maori - 67%; European/other - 59% Edwards R, Wilson N, Thomson G, et al.. N Z Med J 2009;122: 1307.

64. Endgame – overarching strategies May be needed to achieve endgame goals within reasonable timeframe Examples: Regulation of nicotine content Rapidly escalating tax and duty on tobacco products Progressive increase in legal age of purchase for next generation Progressive reduction in retail supply Sinking lid on tobacco imports Structural changes to tobacco market (e.g. regulated market model)

65. Sinking Lid + Adjunct timing/phasing 10% absolute reduction in tobacco products released for sale per year Massive cessation support, mass media + 90% health warnings Display free stores; Plain packaging; no duty freeLicensing retailers; reducing license numbersAlternative nicotine delivery systemsAltering tobacco (e.g. zero nicotine cig.) Thomson et al. Tobacco Control 2010; 19: 431-435

66. Some thoughts about the how? Population vs individual cessation approaches What methods? Some building blocks for success

67. Building block 1: Ongoing generation and use of evidence Generate, disseminate and use evidence of effectiveness at population level and for impact on priority populations Systematic evaluation culture Ongoing research to identify and scope new challenges and issues Monitoring of progress at population level, including: Overarching key markers of denormalisation and social norms (e.g. Chapman and Freeman, Tob Control 2008; 17: 25-31) Population quitting tendency (e.g. Tang et al. - Tob Control 2010; 19: S1 56-61.

68. Evaluation Culture Imperative to carry out thorough evaluation Dearth of evidence (used by opponents) Good practice Evaluation should be: Planned Informed by theory and previous data/literature Multi-faceted (methods, populations, settings) and rigorous Adequately resourced

69. Scottish SF Legislation 1. Semple S,, et al. Bar workers' exposure to second-hand smoke: the effect of Scottish smoke-free legislation on occupational exposure. Ann. Occup. Hyg. 2007;51(7):571. 2. Semple S, et al. Secondhand smoke levels in Scottish pubs: the effect of smoke-free legislation. Tob. Control 2007;16(2):127. 3. Richmond L, et alI. Impact of socioeconomic deprivation and type of facility on perceptions of the Scottish smoke-free legislation. J. Public Health 2007;29(4):376. 4. Phillips R, et al. Smoking in the home after the smoke-free legislation in Scotland: qualitative study. BMJ 2007;335(7619):553. 5. Pell JP, et al. Smoke-free legislation and hospitalizations for acute coronary syndrome. N. Engl. J. Med. 2008;359(5):482-91. 6. Pell JP, Haw S. The triumph of national smoke-free legislation. Heart 2009;95(17):1377. 7. Pell J, et al. Secondhand smoke exposure and survival following acute coronary syndrome: prospective cohort study of 1261 consecutive admissions among never-smokers. Heart 2009;95(17):1415.. 8. Pell J et al. Smoking Ban Significantly Reduces Acute Coronary Syndrome Admissions. JCOM 2008;15(10). 9. Mackay D, et al. Smoke-free legislation and hospitalizations for childhood asthma. N. Engl. J. Med. 2010;363(12):1139-45. 10. Lewis SA, et al. The impact of the 2006 Scottish smoke-free legislation on sales of nicotine replacement therapy. Nicotine & tobacco research 2008;10(12):1789. 11. Hyland A, et al. The impact of smokefree legislation in Scotland: results from the Scottish ITC Scotland/UK longitudinal surveys. The European Journal of Public Health 2009;19(2):198. 12. Hilton S, et al. Expectations and changing attitudes of bar workers before and after the implementation of smoke-free legislation in Scotland. BMC Public Health 2007;7(1):206. 13. Heim D, et al. Public health or social impacts? A qualitative analysis of attitudes toward the smoke-free legislation in Scotland. Nicotine & tobacco research 2009;11(12):1424. 14. Haw SJ,et al. Legislation on smoking in enclosed public places in Scotland: how will we evaluate the impact? J. Public Health 2006;28(1):24. 15. Haw SJ, Gruer L. Research: Changes in exposure of adult non-smokers to secondhand smoke after implementation of smoke-free legislation in Scotland: national cross sectional survey. BMJ 2007;335:549. 16. Haw SJ, Gruer L. Changes in exposure of adult non-smokers to secondhand smoke after implementation of smoke-free legislation in Scotland: national cross sectional survey. BMJ 2007;335(7619):549. 17. Goodman PG, et al. Are there health benefits associated with comprehensive smoke-free laws. International Journal of Public Health 2009;54(6):367- 78. 18. Fowkes FJI, et al. Scottish smoke free legislation and trends in smoking cessation. Addiction 2008;103(11):1888-95.

70. Building block 2: Visions, framing and tactics Need cast iron case and rationale for radical tobacco control measures. Develop and promote a credible and inspiring vision. Identify leaders who can communicate and advocate for the vision. Pay careful attention to advocacy tactics and framing - danger of creating stigma and portrayal as paternalistic, authoritarian etc.

71. Building block 2: Visions, framing and the case for action Need cast iron case and rationale for radical tobacco control measures. Develop and promote a credible and inspiring vision. Identify leaders who can communicate and advocate for the vision. Pay careful attention to advocacy tactics and framing - danger of creating stigma and portrayal as paternalistic, authoritarian etc.

72. The Moral Case for Intervention 1.Smoking is a uniquely hazardous consumer product 2.Most smokers start young 3.Hardly anyone starts smoking as a mature adult 4.Most smokers want to quit 5.Smoking is highly addictive 6.Stopping smoking is very difficult (and the methods to help are not very effective) 7.Almost all smokers regret starting 8.Virtually all smokers dont want their children to start smoking 9.Smoking causes and exacerbates health inequalities and poverty 10.Secondhand smoke harms non-smokers, including children

73. The Moral Case for Intervention 1.Smoking is a uniquely hazardous consumer product 2.Most smokers start young 3.Hardly anyone starts smoking as a mature adult 4.Most smokers want to quit 5.Smoking is highly addictive 6.Stopping smoking is very difficult (and the methods to help are not very effective) 7.Almost all smokers regret starting 8.Virtually all smokers dont want their children to start smoking 9.Smoking causes and exacerbates health inequalities and poverty 10.Secondhand smoke harms non-smokers, including children

74. Exploring an oxymoron: Smoking as an 'informed choice' Combined qualitative and quantitative exploration of informed choice among young adult smokers: Knowledge of smokings addictiveness and range of health risks of smoking Estimates of likelihood of addiction, continued smoking and health risks (? optimism bias) Beliefs about value of later life (? degree of discounting, telescoping) Circumstances of onset of smoking experimentation and becoming a regular smoker (social pressures, alcohol) and impact of knowledge and understanding of risk Compare findings with tobacco industry arguments

75. Building block 2: Visions, framing and the case for action Need cast iron case and rationale for radical tobacco control measures. Develop and promote a credible and inspiring vision. Identify leaders who can communicate and advocate for the vision. Pay careful attention to advocacy tactics and framing - danger of creating stigma and portrayal as paternalistic, authoritarian etc.

76. Head to head Thomson G, et al. Should smoking in outside public spaces be banned? Yes. BMJ 2008;337:a2806 Vs Chapman S. Should smoking in outside public spaces be banned? No. BMJ 2008; 337:a2804

77. Smokefree Parks in New Zealand

78. Stigmatisation and the experience of stigma Tatton L. Smoker stigmatisation: an unintended consequence of smoking denormalisation. Univ of Otago. McCool J et al. Defending the absurd: interpretations of smokers and smoking. Unpublished paper. They think we smell. They try and preach to you. It is really frustrating and annoying. God theyre a pain in the ass. They keep ranting and ranting about the bad things of smoking.. the smell of it. If they dont like it they can go away. She called me a disgusting creature … It does smell really bad, you do the whole kind of wee bit of a cough as you walk past. Just to make sure that they know that you dont really approve of it. Smokers are always pushed out into the outside, away from the non-smokers … it makes you feel.. like the odd one out. They just try and make you feel.. Guilty.. And crap about it… It just makes me want to go and have a cigarette [laughs].. Just to spite them.

79. Means as well as ends are important Means matter in public health and health promotion Bottom-up, broadly-supported, fully debated measures more acceptable, empowering and sustainable Hard won gains may be a blessing

80. The Ottawa Charter for Health Promotion (1986) Build public policies which support health Create supportive environments Strengthen community action Develop personal skills (empowerment) Re-orientate health services

81. The Ottawa Charter for Health Promotion (1986) Build public policies which support health Create supportive environments Strengthen community action Develop personal skills (empowerment) Re-orientate health services

82. Means as well as ends are important Means matter in public health and health promotion Bottom-up, broadly-supported, fully debated measures more acceptable and sustainable Hard won gains may be a blessing

83. 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

85. Deprivation profile of the European and Other ethnic groups

86. Deprivation profile of the Maori ethnic group

87. Deprivation profile of the Pacific Island ethnic group

88. Can the endgame be achieved for all without addressing broader structural determinants? Achieving mass cessation in high prevalence groups is a huge challenge Danger of achieving the endgame only for some and persisting smoking viewed as a problem for a marginalised section of society – which can be ignored.

89. 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

90. Questions for you What might the vision or endgame scenario look like for you? What measures will work in your setting? How can you ensure that the endgame vision is communicated to all sections of the community and key stakeholders? How can you make the paradigm shift, develop a credible and inspiring vision and strategy, and achieve your endgame? How can you ensure that you are part of the movement for wider change to achieve broader public health goals and social justice?

91. Kia ora Thank you