Tobacco Control Policy, Illicit Drug Policy, and Public Health Responses

Tobacco Control, Illicit Drug Policy, and Public Health Responses

Tobacco Advertising (1920s-1940s)

• Advertisements made implied health claims (e.g., "smooth", "clean", "kind to your throat").

• Filter-tip cigarettes were marketed and falsely advertised as a means of reducing health risks.

  • Before 1950, filter-tips made up only $0.6\%$ of the market.

  • By 1960, they accounted for $51\%$ of the market.

  • By 2005, filter-tips were $99\%$ of the cigarette market.

• Filters gave smokers as much or more nicotine and tar as regular cigarettes, despite being perceived as less risky.

• Filter ventilation produced lower tar and nicotine readings when smoked by a machine but not by people.

Health Risks of Smoking

• 1964 Surgeon General's Report (SGR):

  • $70\%$ increase in overall mortality rate.

  • Causes lung cancer and has a dose-response relationship.

  • 9- to 10-fold risk of lung cancer for average smoking.

  • 20-fold+ increased risk of lung cancer for heavy smoking.

  • Causes chronic bronchitis and emphysema.

  • Smoking during pregnancy reduces birthweight.

  • Associated with coronary heart disease.

• 2014 SGR:

  • Causes lung, liver, colorectal cancer, COPD, CVD, ectopic pregnancy and maternal smoking causes orofacial clefts and erectile dysfunction, neovascular and atrophic macular degeneration, and diabetes (including dose-response), and rheumatoid arthritis.

  • Secondhand smoke causes cancer, respiratory and CVD issues, and adverse health effects for infants and children.

  • Suggestive (but insufficient) to infer cause of breast cancer, asthma, idiopathic pulmonary fibrosis, maternal smoking and childhood behavioral disorders, miscarriage, age-related macular degeneration, dental caries and implant failure and Crohn’s disease.

  • Increases risk of TB, lung infections, and several disorders with an underlying immune diathesis.

  • Contributes to disease progression for prostate cancer, causes adverse health outcomes for cancer survivors, exacerbates asthma, and reduces effectiveness of the tumor necrosis factor-alpha ($TNF-\alpha$) inhibitors.

• Evidence of adverse health impacts has grown over time.

Industry Responses to Health Concerns

• Casting doubt on the science.

• Researching ways to reduce harmful chemicals in cigarette smoke.

• Producing products with the appearance of lower risk.

• Internal documents reveal that the industry aimed to provide consumer reassurance, e.g., by claiming or creating the perception of low tar deliveries and mildness.

Tobacco Industry Exposed as Lying

• Damages suits by State Attorneys General in 1994 forced the release of internal industry documents.

• The Master Settlement forced the tobacco industry to acknowledge harms and pay $206$ billion over $25$ years.

• Internal documents undermined TI credibility, revealing that the industry:

  • Knew about addictiveness and harms.

  • Manipulated nicotine levels of cigarettes.

  • Publicly denied harms and addictiveness.

  • Spuriously reassured smokers via “lights”, etc.

Public Health Responses to Tobacco in Australia (Timeline)

• 1973: Health warnings first mandated on all cigarette packs.

• 1976: Bans on all cigarette advertising on radio and television.

• 1986 to 2006: Phased in bans on smoking in most workplaces and public places.

• 1994 to 2003: Bans in restaurants.

• 1980s and 1990s: Packs of < $20$ cigarettes banned across Australia.

• 1990: Bans on advertising of tobacco products in newspapers and magazines.

• 1992: Tobacco tax increase.

• 1993: Tobacco Advertising Prohibition Act 1992 prohibited broadcasting and publication of tobacco advertisements.

• 1995: Nationally consistent text-only health warnings required.

• 1998 to 2006: Bans on point-of-sale tobacco advertising across Australia.

• 2005: ‘Light’ and ‘mild’ descriptors banned as ‘misleading conduct’.

• 2006: Graphic health warnings required on packaging of most tobacco products.

• 2008: Fruit and confectionary flavored cigarettes banned across Australia.

• 2010: $25\%$ increase in the tobacco excise.

• 2011: First complete state or territory ban on point-of-sale tobacco product displays.

• 2012:

  • Offence for any person to publish tobacco advertising on the internet or other electronic media.

  • Introduction of tobacco plain packaging, and updated and expanded graphic health warnings.

• 2012 and 2017: Reduction in the duty free allowance for tobacco products.

• 2013 to 2020: Annual $12.5\%$ tobacco excise.

• 2017: Tax harmonization for roll-your-own tobacco and other products such as cigars, with manufactured cigarettes.

• 2022: New measures announced by Federal Health Minister include:

  • Ban on menthol flavored cigarettes.

  • 'Dissuasive sticks with warnings printed on stick'.

  • Pack inserts with quit information.

  • Standardized size of tobacco packs.

  • Standardized cigarette filters.

  • Banning descriptors like ‘organic’ and ‘light’ on tobacco products. Will be implemented in July 2025.

Other Tobacco Control Measures

• National and State/Territory anti-smoking advertising.

• Quitline services.

• Subsidized smoking cessation treatment (e.g., nicotine patches and prescription medicines).

Impact of Public Health Measures in Australia

• Australian smoking prevalence:

  • 2022/23:

    • Current smoking: $11.1\%$.

    • Daily smoking: $8.1\%$.

    • Age 18+; ‘current smoking (includes daily and non-daily).

  • Smoking is still the leading risk factor that contributed to disease burden and deaths.

  • $76\%$ of the lung cancer burden.

  • $73\%$ of COPD burden.

  • >50\% of esophageal cancer burden.

  • Tobacco use contributed the most to fatal burden ($\sim 20,500$ deaths or $13\%$ of all deaths) in 2018.

• Smoking prevalence trends:

  • Decreasing, especially among higher socioeconomic status (SES) groups.

  • Absolute difference between SES groups is decreasing, but in 2022/23, the lowest SES group was 2.3x the highest SES group, larger than in 2010 (2.0x).

• Smoking rates remain disproportionately high among Aboriginal and Torres Strait Islander peoples.

• Higher prevalence of daily smoking among people with mental health and substance use disorders.

The Commercial Tobacco Endgame

• Explicit government goal of close to zero smoking prevalence (sometimes interpreted as < $5\%$.)

• Target end date (maximum of $20$ years).

• Clear strategy for achieving it - current incremental approaches probably not sufficient.

• Initiatives designed to change/eliminate permanently the structural, political and social dynamics that sustain the tobacco epidemic, in order to end it within a specific time.

• Examples of countries with endgame goals:

Illicit Tobacco

• Illicit tobacco = any products for which legally-required taxes have not been paid.

• Products include unbranded loose-leaf tobacco (“chop-chop”) and illegally imported foreign-branded packs.

• Reasons to be concerned about Australia’s growing illicit tobacco market:

  • Undermines tobacco control policies (e.g., tax increases; plain packaging).

  • Disproportionately affects people on low incomes.

  • Lost tax revenue (e.g., $2.8$ billion in 2021/22).

  • Organized crime involvement.

Illicit Drug Policy in Australia

• An increase in illicit drug use is driven by hallucinogens.

• Almost 1 in 5 people in Australia ($17.9\%$) had used an illicit drug in the previous 12 months in 2022-2023.

Drug Policy in Australia

• National Drug Strategy (2017-2026):

  • Supply reduction (e.g., drug law enforcement, customs).

  • Demand reduction (e.g., treatment services, drug education campaigns).

  • Harm reduction (e.g., needle and syringe programs, drug checking).

• Federal expenditure relating to illicit drugs (2021/22 financial year):

  • Total spent: $5.45$ billion (compared to $1.6$ billion in 2009/10).

  • Law enforcement: $64.3\%$ of expenditure.

  • Treatment: $27.4\%$ of expenditure.

  • Prevention: $6.7\%$ of expenditure.

  • Harm reduction: $1.6\%$ of expenditure (down from $2.2\%$ in 2009/10).

Possible Responses

• Full prohibition: Drug use, possession and supply are criminal offenses.

• Decriminalization: the removal of criminal penalties for drug use or possession.

• Legalization: use of a drug is legal as is drug supply.

• There is strong public support among Australians for decriminalization.

• Evidence suggests that decriminalization:

  • Reduces the costs to society, especially the criminal justice system costs.

  • Reduces social costs to individuals, including improving employment prospects.

  • Does not increase drug use.

  • Does not increase other crime.

Example of Drug Policy Response: Portugal

• Decriminalized all drugs in 2001.

  • Significant decreases in overdoses, HIV infection and drug-related crime.

  • Those possessing drugs are given a warning/ small fine/ appear before a local commission.

  • Links to treatment and support services.

  • Shifts in language from drogados (junkies) to “people who use drugs” or “people with addiction disorders”.

Example: Cannabis in Australia

• ACT: Persons aged 18+ can legally possess:

  • $50g$ of dry material

  • $150$ grams wet material

  • cultivation of 2 plants per individual/ 4 plants per household

Changes to Queensland's Drug Penalties

• Queensland's Police Drug Diversion program will be expanded to include the minor possession of all types of drugs by implementing a new tiered approach:

  • $1^{st}$ minor drug-possession offense - a police officer issues a warning, accompanied by a drug warning notice and a police referral to a support service.

  • $2^{nd}$ and $3^{rd}$ minor drug-possession offense - a police officer offers the opportunity for the person to participate in a mandatory Drug Diversion Assessment Program.

  • $4^{th}$ minor drug-possession offense - a police officer issues the offender with a notice to appear in court.

  • penalty for drug trafficking will increase from 25 years imprisonment to life imprisonment.

Drug Checking

• Also known as pill testing.

• Harm reduction strategy.

• Chemical analysis of contents of a substance by trained chemists.

• Aims to inform service users whether their substance is what they expected or not, and whether it contains any dangerous or undocumented substances, or is of higher purity than expected.

Drug Checking at Music Festivals

• 6 Australians died at music festivals in 2019-2020; 1 in Feb 2023 from drug-related causes.

• $64\%$ of a national sample of Australian festival attendees reporting using illicit drugs at the most recent festival they attended (Hughes et al., 2019).

• E.g., MDMA overdose- hyperthermia, seizures, hyponatraemia (electrolyte abnormalities), rhabdomyolysis (breakdown of muscle tissue), and multi-organ failure causing death.

Drug checking in Australia

• Personal testing kits are legal but inaccurate (can only tell you if main drugs are present, can only identify ‘main’ drug).

• First drug checking trial conducted at Groovin’ the Moo in Canberra in 2018

CheQpoint in Queensland

Drug checking at music festival, with service workers finding many unsafe samples.
From April to December, 490 people visited CheQpoint Brisbane and Gold Coast.
A total of 800 samples expected to be either 'psychoactive drugs' (652 samples) or 'steroids' (148 samples) were presented for testing across 418 presentations.
48% had never talked to a health worker about alcohol or drug use.
Other major finds in samples include dimethyl pentylone, ethyl bromazolam, and nitazene in counterfeit oxycodone tablets.