Tag Archives: lung cancer

The policy termites slowly eating out the foundations of smoking

The Conversation

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Like a mound of termites, tobacco control policies are eating away at smoking in ways we’re not always conscious of. from www.shutterstock.com

Simon Chapman, University of Sydney

Across 40 years of working in tobacco control, there have been countless times when I’ve been asked “so, has [insert here] policy or [insert here] campaign worked?”.

The question has its roots in clinical interventions where we see what happens when you take an analgesic for pain, get an injection before having a tooth pulled, or apply a fungicide on athlete’s foot. These things work.

So it’s natural we should ask the same about a piece of legislation or a multi-million dollar TV campaign about smoking. Do these things make a difference?

In 1993 I wrote an essay on this issue in the British Medical Journal, Unravelling gossamer with boxing gloves: problems in explaining the decline in smoking.

In the wake of Philip Morris being ordered to pay the Australian government about A$50million in legal costs over the company’s failed attempt to thwart plain packaging, I was asked the question again this week: “Has plain packaging worked?”

So here’s an update on the direct and subtly synergistic ways tobacco control has seen Australia achieve record lows in both adult and teenage smoking.

From a trickle to a deluge

Since the bad news on smoking and health began to trickle in from 1950, then deluged us, hundreds of millions of smokers have stopped smoking around the world, particularly in nations where governments have introduced population-focussed laws and regulations. These include measures like laws, taxes and mass campaigns that reach huge proportions of the population as opposed to dinky little interventions very few people ever see or are exposed to.

When a smoker decides to quit, they will have usually tried before – many with about the same conviction as attempts to exercise more or lose weight. But when they finally succeed, ex-smokers will often nominate a reason “why” they quit.

There is broad daylight between the first reason ex-smokers give about why they quit and all other reasons they nominate. Health concerns are the overwhelming reason for quitting (91.7%), followed by cost (way back at 58.7%); 90% of smokers regret they ever started.

The straw the broke the camel’s back

People also often nominate a recent “straw that broke the camel’s back” as the precipitating reason for the final decision to quit and resolve to see it through.

This can be a symptom they have experienced, an incident like the sudden death of a smoking friend, a particularly poignant campaign advertisement they can’t get out of their head (this classic has few peers), the heartfelt pleading by a child or partner, the sudden realisation very few of their colleagues or friends smoke or the price of cigarettes going through a psychological barrier, like A$40 a pack.

These triggers are known as proximal factors that stimulate quitting: factors easily identified, nominated by smokers aware of their influence, and sometimes easy to quantify with proxy measures like immediate boosts in calls to quitlines.

Background factors that eat away at smoking

But there are also vital distal or background factors that work like hidden termites in a building. These slowly and subconsciously eat away the foundations of smokers’ feelings of being invincible to disease, their apathy and act to denormalise pro-smoking environments. The effect is that smokers get fewer reminders about smoking and a growing awareness smoking is not something the great majority of people do anymore.

Examples of these distal factors are advertising bans, graphic warnings on packs, plain packaging, smoke-free public spaces and tobacco taxation.

Very few smokers tell you they quit smoking because tobacco advertising was banned. The impact of advertising bans instead works in slow-burn fashion, as it has done in Australia since 1993 when the last forms of advertising ended.

With plain packs, some smokers experienced an increased urgency to quit after exposure to the purposefully unappealing plain packs with their goullish (but deadly accurate) large graphic health warnings. But the primary goal was to have whole generations grow up never having being beguiled by the designer edginess of pack livery and noting plain packaging of tobacco products was exceptional among all other consumer goods.

Tobacco is the only product where legislation mandates plain packaging: 17 nations have either implemented, legislated it or announced they will. Tobacco is also the only product that has to be stored out of sight in retail outlets.

All these factors do not act in isolation, but like a constant and unstoppable termite colony, working in synergy to erode the appeal of smoking.

A day in the life of an ex-smoker

In my 1993 BMJ essay, I described a day in the life of a smoker who quit. The smoker woke to news on the radio of yet more bad research news about smoking; lived with disapproving family members who often urged him to quit because they had been educated about the risks; winced every time at the price he had to pay for a pack; was acutely aware of all the places he couldn’t smoke and why those laws had been introduced; was self-conscious about the stench of stale tobacco he carried about; and couldn’t shake some of the powerful anti-smoking advertising that intruded his TV viewing.

A smoker might well nominate just one of these influences when a researcher calls, but all play a part in a comprehensive approach to reducing the world’s leading cause of death, if you exclude poverty.

Humans are not like lab rats who can be artificially kept in strictly controlled environments and exposed to single or fixed combinations of policy variables while isolated from all others so researchers can measure the exact impact of any one factor.

The ConversationPeople whose questions are based on that premise need to be gently reminded of that. Male lung cancer incidence rates today were last seen in the early 1960s and women’s seem likely to never reach even half the peak seen at the height of the male epidemic. We need to stay the course and make smoking history.

Simon Chapman, Emeritus Professor in Public Health, University of Sydney

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.

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How the tobacco industry is gaming Australian health regulations

The Conversation

Steven Greenland, Swinburne University of Technology

Australia’s tough tobacco regulations are acting as a catalyst for the industry to develop sophisticated marketing practices. These companies are gaming the system by anticipating regulatory impact and then using unregulated marketing elements to overcome it.

Australia has been a guiding light for countries looking to improve public health through the effective regulation of tobacco, which remains the world’s biggest cause of preventable illness and death, and still kills around 15,000 Australians annually.

December 2012 saw the implementation of Australia’s innovative plain packaging legislation, this was followed by four 12.5% annual tobacco tax excise increases. As a result the number of Australian smokers has fallen to a record low.

However the tobacco industry has used several strategies, including price reduction, brand differentiation and promoting the idea of healthier cigarettes, to undermine Australia’s new regulatory environment.

Plain packaging was introduced in 2012 to much fanfare, but tobacco companies are making serious efforts to alleviate the effects of plain packaging on their bottom line.
Lukas Coch/AAP

Pricing for packets

To offset price hikes manufacturers have expanded lower priced product ranges, with new ultra low priced brands. One example of this is the British American Tobacco Australia’s (BATA) Just Smokes, which sells for around 70% of the premium brand prices. BATA has also shifted Rothmans, previously a premium brand, into the economy segment by cutting its price by more than 30%.

Another pricing initiative is twin pack promotion. Most consumers recognise that progressively larger packs offer progressively lower unit prices – a lower cost per single item or single pack.

This used to be true for tobacco, with the largest cartons (usually with 200 cigarettes) offering best value. However, since 2012 discounted twin packs represent best value.

A supermarket twin pack, per cigarette price, is up to 10% cheaper than single packs – effectively discouraging single pack purchases. Australia’s leading brand Winfield twin pack, per cigarette price, is equal to or below that of larger cartons.

Regulatory price increases are financial deterrents to smoking. The low price branding and discounting strategies in Australia are clear attempts to get around these, and reduce smokers’ financial motivation to quit or cut down.

Heavily discounted twin packs also teach smokers, through financial reward and penalty, to buy twin rather than single packs. This is of particular concern since research shows that larger purchases trigger higher consumption.

In 2014 the industry claimed tobacco consumption had actually increased after plain packaging. While this was disproved, it suggests big tobacco anticipated increased consumption as smokers switched to twin pack purchase behaviour.

New tobacco products and promotions

Plain packaging was expected to restrict tobacco brands. However, after 2012 manufacturers introduced numerous new products, and brand ranges actually expanded.

For example, Australia’s leading brand Winfield supported more than 20 brand variants in 2015-2016 compared to just 12 in 2012-2013. Brand differentiation is a proven marketing approach for generating greater sales, with each variant targeting a specific consumer market segment.

Since plain packaging was introduced, tobacco companies have varied the names of brands as well. Names have evolved to include the information previously covered by packaging, such as colour and new product features. For example, Dunhill Infinite is now Dunhill Infinite White + Taste Flow Filter.

Today around 80% of Australia’s leading brands’ variant names include a colour, compared to less than half before plain packaging. Tobacco companies are also using colours to mislead consumers that certain product ranges are “healthier” options.

A universal colour code has been promoted by the industry in which smokers interpret lighter colours (white, silver, gold, yellow and blue) as being less harmful, and darker colours (red and black) as more harmful. Before plain packaging colour hues were a pack design component, now the myth of healthier tobacco options is perpetuated by colour names. This is disturbing from a public health perspective as it represents industry efforts to lessen smokers’ health motivations for quitting.

The effects of clever marketing

Australia’s tobacco regulations have significantly reduced smoking. However, their impact would be greater without unscrupulous industry initiatives to overcome and thwart them.

Industry response to plain packaging and excise increases have not been simple marketing efforts to increase sales, but illustrate cynical attempts to reduce financial and health motivations for quitting, and to encourage smokers to smoke more. Australian regulators, and those in other countries, should therefore consider further regulation.

Research suggests that future effective controls might include:

  • Introducing a standard fixed per stick price for all cigarettes – preventing differentiation by price and cheaper brand options
  • Prohibiting price variation by pack size – preventing volume discounting or twin pack promotion that encourage smokers to make larger purchases and smoke more
  • Restricting pack size to a maximum of 10 or 20 cigarettes to limit increased consumption associated with larger pack sizes
  • Banning colour variant names – removing colour-health connotations
  • Restricting brand variant ranges, for example to one variant or representation per brand, to limit the way tobacco companies use differentiation to increase sales.

The tobacco industry is committed to gaming regulations, like plain packaging and tax excise increases, and developing approaches to undermine their impact. However, the Australian government is equally committed to reducing the national adult daily smoking rate to 10% by 2018. The additional tobacco controls outlined above should help the government achieve this.

The ConversationSteven Greenland, Associate professor, Swinburne University of Technology

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.

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Smoking: new Australian data to die (or live) for

The Conversation

By Simon Chapman, University of Sydney

A new study of deaths from all causes in New South Wales published today in BMC Medicine (open access) reports both some very bad and very good news about smoking.

Up until now, Australian estimates of the death and disease risks of smoking have been modelled from large-scale British and United States cohort studies, where researchers followed very large groups of people across many years and compared the death records of “never smokers” with smokers and ex-smokers.

Now, for the first time, we have local cohort data. The 45 and Up study commenced in 2006 and tracked 204,953 people for an average 4.26 years (a total of 874,120 person years).

Researchers recorded participants’ smoking status (when the study started and at various follow-ups) and, where applicable, hospitalisations and death.

Overall, there were 5,593 deaths from all causes, with current smokers nearly three times (2.96) more likely to die than never or former smokers.

The two stand-out results are that up to two-thirds of the deaths in current smokers were due to smoking (the bad news) and that death rates in former smokers who had quit before turning 45 were not different from those in the study who had never smoked (the very welcome news).

As other studies have reported, the smokers in this study died, on average, ten years earlier than the never smokers. With the life expectancy in Australia at 82.1 years, smokers are losing an average of one day in eight off their lives.

So, a person who started smoking at 15, who smoked an average of 15 cigarettes a day and died at 72, would have smoked 312,288 cigarettes in their lifetime. These each take about six minutes to smoke.

Across 57 years of smoking, this translates to 3.56 years of continual smoking, meaning that each cigarette on average can be expected to shave about 2.8 times the time it takes to smoke it off the end of smokers’ lives.

We’ve known for some time that smoking adversely affects almost every body organ and bodily system, from the eyes to the toes.

Big population health data sets now allow us to understand that the list of previous diseases caused and exacerbated by smoking was very conservative. A major US study published this month pooled five contemporary US cohort studies including 421,378 men and 532,651 women followed from 2000 to 2011. It found:

17% of the excess mortality among current smokers was due to associations with causes that are not currently established as attributable to smoking.

These associations included deaths from renal failure, hypertensive heart disease, infections, breast and prostate cancer.

When Sir Richard Doll’s 40 year follow-up of his historic British doctors study was published in 1994, the take-home message was “half of all regular cigarette smokers will eventually be killed by their habit”.

We can now say with confidence that up to two-thirds of smokers will die from their smoking, on average ten years early.

Stopping smoking before age 45 appears to eliminate most of this risk.

Only about one in ten smokers do not regret having started, and today there are twice as many ex-smokers than there are daily smokers. Most have quit without any professional or pharmacological assistance.

When American surgeon Dr Alton Ochsner* was a medical student in 1919, he was summonsed to see a lung cancer operation, and told that this was a rare disease that he might never see again. He didn’t see another case for 17 years. Then he saw eight in six months – all smokers who had picked up the habit in WWI.

Today, lung cancer is the biggest case of cancer death is the world. It is an epidemic spread by the tobacco industry, facilitated by government inaction. An article in the journal Nature in 2001 forecast that a billion deaths will be caused by tobacco this century.

Nations that have taken tobacco control seriously, such as Australia, Canada, Britain and the United States, are leading the way in dramatically reducing smoking rates. This new data will strengthen that resolve.

* This article originally named the American surgeon as William Osler. This has now been corrected.

Editor’s note: please ensure your comments are courteous and on-topic.

The ConversationThis article was originally published on The Conversation. (Reblogged by permission). Read the original article.


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