Tobacco smoking is the largest single preventable cause of death and disease in Australia today. Smoking is estimated to have caused 18,920 deaths in Australia in 1992,(1) over nine times the number of road crash fatalities.(2) Of drug caused deaths, 82% are due to tobacco, 16% are due to alcohol (including road crash fatalities) and 2% are due to illicit drugs (including narcotics, cannabis, hallucinogens, stimulants and non-prescribed tranquillisers). Tobacco usage is widespread in the community, with about one quarter of the adult population smoking regularly.(3)
Tobacco smoking as we now know it is a relatively recent phenomenon, more recent than the automobile, the aeroplane and telephone.(4) Although tobacco has been smoked, chiefly in pipes and cigars, or sucked and chewed by a number of different societies, some for many centuries, the development of the manufactured cigarette in the late nineteenth century substantially changed smoking habits forever.
Manufactured cigarettes, made by a combination of hand and machine, and later machine alone, were first marketed in England in the 1850s, and in Australia in the following decades. Although at first regarded as a hooligan's alternative to pipes or cigars, they were convenient to use and widely available, allowing consumption levels to increase. Their convenience in the trenches during the First World War did much to extend their popularity and more than 60% of tobacco donated to the Allies on the Western Front was in the form of cigarettes.(5)
In the years between the two world wars, tobacco use as a male preserve was increasingly eroded by women.(6) Following the Second World War, nearly three-quarters of the male adult population, and about one-quarter of adult females were smokers.(7) This is not surprising: cigarettes were widely available and relatively inexpensive. And everybody appeared to be doing it -- movie stars, sporting heroes, even doctors(8) were used in advertising endorsements. Cigarette use was ubiquitous. What was not recognised was that it was also highly addictive and deadly.
Cigarettes encouraged different patterns of inhalation compared to other tobacco products. People primarily use tobacco for the effects gained from nicotine, the addictive drug it contains. Pipes, cigars and chewing tobacco produce nicotine in an alkaline environment, enabling absorption through the lining of the mouth. The more acidic smoke of cigarettes, however, necessitates inhalation into the lungs for effective uptake of nicotine.(9)
While the other forms of tobacco use certainly carry a burden of disease for their users, cigarettes, because of their frequency of use and depth of inhalation, produce far more disease.
The rise in the incidence of lung cancer was first observed during the 1920s and 1930s by pathologists and other medical practitioners as patient admissions increased.(10,11) The first official body to express concern was the UK Registrar General,(12) and these concerns resulted in independent parallel investigations being commenced in the UK and the USA in 1948.(13,14)
As tobacco use in some form or another was as old as history itself, the concept that it could be implicated in development of disease verged on the unthinkable: the leap in lung cancer had to have some other explanation. In describing the background to the English study, Sir Richard Doll said of his research in 1948:
What we did was to list all the possibly relevant factors that we thought people could have been exposed to and which could have become more prevalent over the previous 50 years. There weren't very many and one of them was smoking and particularly the smoking of cigarettesâ But cigarette smoking was such a normal thing and had been for such a long time that it was difficult to think that it could be associated with any disease.(12)The research of Doll and Bradford Hill in the UK,(13) and Wynder in the US,(14) reported that smoking and lung cancer appeared to be causally linked. Both studies were published in 1950.
Research over the following decade confirmed these findings, and by the late 1950s and early 1960s, the evidence that smoking was a cause of disease and death in western society was clear. In July 1957, the US Public Health Service issued its first statement on cigarette smoking, identifying it as a cause of lung cancer.(15) The major reports of the Royal College of Physicians of London in 1962(16) and the US Surgeon General in 1964(17) hailed the beginnings of the anti-smoking movement with the recognition that smoking was a major cause of disease. In the foreword to the 1964 Report, the US Surgeon General commented that 'few medical questions have stirred such public interest or created more scientific debate than the tobacco-health controversy'.(17)
Cigarette use is therefore the result of a tragic accident of history. The true extent of tobacco's health dangers only began to emerge well after its use was firmly entrenched in the community. This fact, and the fact that cigarettes are made by large and powerful companies which have gone to great lengths to protect their business interests, have given the introduction of responsible health policy a measure of difficulty unparalleled in the history of public health.
With the release of the overseas reports on smoking and health, Australian medical and health organisations immediately called for government action. In October 1962, the Australian Medical Association (AMA), the Royal Australasian College of Physicians (RACP), the Royal Australasian College of Surgeons (RACS), the Royal Australian College of General Practitioners and the Anti-Cancer Council of Victoria endorsed the 1962 Report of the Royal College of Physicians and recommended restrictions on tobacco advertising and the introduction of a public health education campaign. Three years later a deputation of the AMA, RACP, RACS, the Royal College of Pathologists of Australasia, the National Heart Foundation of Australia, the National Tuberculosis and Chest Association and the Australian Cancer Society requested that the Federal Minister for Health introduce measures including advertising restrictions and the establishment of regular surveys into the smoking habits of Australians.(5)
Whereas the governments of the United Kingdom and New Zealand banned cigarette advertising on television in 1964 in response to a call from medical authorities in those countries, the call by Australian medical authorities went unheeded by government until nearly ten years later. This was the first time that conservative medical opinion on the solution to a major public health problem was ignored by government, in contrast to the successes in Australia of controlling the cholera, tuberculosis and polio epidemics.(18) The thinking by parliamentary leaders at the time is exemplified by comments made in 1971 by the Treasurer of the then Liberal Federal Government, Mr Billy Snedden, who declared in Parliament that he had seen no proof that cigarette smoking led to lung cancer and heart disease.(5)
Although governments failed to act and the efforts of the health authorities were marginalised, the media informed the public of the accumulating scientific evidence of the health dangers of smoking, and male smoking prevalence rates were observed to fall.(7) The reporting of the health dangers of smoking by the free press in this way in countries such as Australia, New Zealand, Canada, the UK and the US contrasts with the lack of similar reporting by news agencies in the then Eastern bloc countries.
It was not until the following decade that the Australian tobacco industry suffered its first restraints. In 1972, for the first time, a mandatory health warning was required on cigarette packages and direct advertising in the broadcast media was phased out between 1973 and 1976. These restrictions were anticipated by the tobacco industry, and it developed strategies to circumvent the effect of such proposals. The minutes of a Rothmans management meeting held in November of 1970 give a clear indication of their thinking at that time:
Discussing smoking and health, Mr Watson [general manager] advised that we can expect more severe attacks on the industry in the near future. In Canada and the USA, advertising restrictions are pending, and in the UK, there is no cigarette advertising other than press. We can expect similar restrictions here within the next few years. This is the reason for the existence of the Rothmans National Sport Foundations and our sponsorships which are being developed in anticipation of restrictive advertising action in Australia.(19)The continued broadcast exposure for tobacco companies gained through sport and cultural sponsorship, and the relative ineffectiveness of the early health warning legislation, made these initial controls little more than an inconvenience to the industry, although they doubtless signalled that the Australian marketplace could no longer be taken for granted.
The 1980s provided a far greater series of challenges for the tobacco industry. As is generally the pattern in affluent societies, growing prosperity is accompanied by improved education and a concern for quality of life.(20) Drug use and abuse became a major focus of government and community attention during the mid 1980s, with growing outrage being expressed at the social and economic costs to society of licit and illicit drug use. Despite the best efforts of the tobacco industry to deflect attention from their products, tobacco received wide publicity as Australia's number one drug killer,(21) with massive attendant health costs.(22) Further, it is likely that the persisting intransigence of the tobacco companies, which continue to deny the link between smoking and disease, has greatly diminished their credibility and hence public sympathy for their arguments.
These views have been reflected by public policy. At a state level, a number of attempts at legislating to ban tobacco advertising and impose controls on a variety of aspects of tobacco production and sales have occurred,(23,24,25) with the first major successes occurring in South Australia in 1986,(26) and in Victoria with the landmark Tobacco Act in 1987.(27) The Victorian legislation, which among other things banned most remaining forms of tobacco advertising and promotion and established a Health Promotion Foundation, provided a model which has since been replicated in South Australia, the ACT and Western Australia, and has also received widespread international interest. Tobacco advertising bans were passed in the New South Wales parliament in 1991, which meant that 80% of the population of Australia were now covered by legislation banning tobacco advertising. Federal activity resulted in the announcements of smokefree policies in federal workplaces in 1986,(28,29) smokefree travel on domestic aircraft in 1987, and an end to tobacco advertising nationally in the print media in 1989. In December 1992, the federal parliament passed legislation phasing out most remaining forms of tobacco advertising by 1995.(30)
But far more threatening to the long term viability of the tobacco industry has been the emergence of the passive smoking issue, which has marked a major turning point in public attitudes towards the industry, and has mobilised a far greater proportion of the community than had previously been prepared to take a public stance about tobacco.
Unequivocal evidence detailing the dangers of exposure to tobacco smoke to infants had become apparent during the 1970s.(31,32,33) For non-smoking adults, the first summary of the dangers of passive smoking appeared in 1985,(34) and was confirmed the following year by three other independent, authoritative scientific committees.(35,36,37) However the tobacco industry had long been aware of the threat of passive smoking. In 1978 a survey had been commissioned by the US Tobacco Institute (the lobbying arm of the US tobacco manufacturers, similar to the organisation of the same name in Australia) on future directions for the industry.(38) Chief among the findings was the view in the community that passive smoking might be dangerous. This meant that the health effects of smoking would be of considerable concern to everyone: no longer could smokers be said to be harming only themselves. The survey identified the passive smoking issue as 'the most dangerous development to the viability of the tobacco industry that has yet occurred', and went on to suggest that 'the strategic and long run antidote to the passive smoking issue ... [was] ... developing and widely publicising clear-cut, credible, medical evidence that passive smoking is not harmful to the non-smoker's health'.
Despite meticulously following the recommended tactics, the tobacco industry can now be said to have lost the passive smoking debate. Smoking is now banned in most forms of public transport, including domestic aircraft. Offices and organisations are embracing non-smoking policies in ever increasing numbers, not least because of the fear of litigation. Australian estimates have shown significant declines in cigarette consumption attendant with smoking restrictions in the workplace.(39) And in a king-hit to the industry, early in 1991, in a case which attracted international media attention, the Australian Federal Court found that the Tobacco Institute of Australia was in contravention of provisions of the Trade Practices Act by publishing misleading information about the extent of medical and scientific evidence on the health effects of passive smoking.(40)
While significant real tax increases, the most effective deterrent to tobacco smoking, have not been part of the anti-smoking landscape in Australia until recent years, the combination of factors described above has given rise to optimistic indications that tobacco consumption will continue its downward trend. Male smoking rates have fallen from 72% in 1945 to 28% in 1992. Female smoking rates increased from 26% in 1945 to 33% in 1976, but have fallen back to 24% in 1992.3,7 Per capita consumption has declined by 31% between 1984 and 1993.(41)
In Australia, disease outcomes are also improving for men. Using lung cancer death rates as an indicator of tobacco attributable mortality, male rates decreased by 5.5% between 1980-84 and 1985-89, a statistically significant drop. Female rates increased significantly by 15% over the same period, and while this continues to alarm, there is evidence that the rate of increase has started to slow.(42)
Where are the major battle grounds now? There is still much to be achieved. Removal of the remaining tobacco advertising from television screens is an obvious priority, and this has been addressed by the federal government in the Tobacco Advertising Prohibition Act 1992.(30) The trend towards reduced student smoking seen throughout the 1980s appears to have ended,(43) an obvious area for concern. Despite the existence of legislation in each Australian state and territory banning the sale of tobacco products to minors, children as young as twelve purchase cigarettes with comparative ease from retail outlets.(44,45) Although there is good evidence from overseas that the proper enforcement of sales bans is effective in reducing smoking among young people,(46) Australian prosecutions for selling cigarettes to minors are few and attract token penalties.(45) Although many organisations now have workplace smoking restrictions, many public places -- for example restaurants, hotels and some shopping malls, still do not. Cigarettes remain relatively inexpensive and widely available, and despite carrying some health and contents information, fall far short of the labelling compulsorily carried by other drugs and foodstuffs in Australia.
According to the World Health Organization and the International Union Against Cancer (UICC),(47) an effective reduction in tobacco consumption can be achieved by a number of interrelated measures being taken. The objectives of a comprehensive smoking control program, based on the UICC proposal, are:
the achievement of lower smoking rates in all age groups of the population, by the application of all practical downward pressures on smoking rates, including health warnings on tobacco packets, increased taxation, restrictions on smoking opportunities, support for the rights of the non-smoker, and information and education programs;
the encouragement of non-smokers to remain non-smokers -- the emphasis is on children and adolescents because most people who smoke, commence before adulthood;
the cessation of all forms of tobacco advertising and promotion;
the encouragement of those who have not yet stopped smoking, and therefore remain at high risk, to reduce, as far as possible, their exposure to the harmful components of tobacco smoke;
maintaining liaison with other health organisations and authorities to ensure maximum effectiveness and to avoid conflict of activities.
The objectives recommended by the UICC are synergistic, in that the greatest impact is obtained if all components are acted upon. However, in the short term, increasing the price of cigarettes by tax changes and restrictions on smoking in public places are likely to yield more immediate impacts on tobacco consumption. Over the medium to longer term, education of the public through news reports and media campaigns, schools, and the teaching of parents will accelerate reductions in tobacco consumption.
Competing against these measures are the influences orchestrated by tobacco companies which encourage smoking. These include their advertising and promotional activities and lobbying activities designed to ensure that governments take minimal or no action that will lead to a reduction in consumption. The political leverage of the tobacco industry should not be underestimated, and its lobbying powers have been well documented in Australia and overseas.(48,49) It has become apparent that if change is to occur in the interests of the health of the public, then health professionals must unite in order to resist the considerable power of the tobacco lobby.
Despite some notable advances for public health in the past two decades, the success of future initiatives cannot be taken for granted. Australian controls have largely occurred on a piecemeal basis; we are yet to see a concerted, coordinated effort combining the elements of the comprehensive strategy described above to reduce the death rates caused by our number one drug killer. There is no shortage of excellent theory (some of which is outlined in Appendix II): what has been lacking is the political consensus to transform theory into action.
This introduction has been published by the Journal of Drug Issues(50) in a slightly altered format. It has been updated with recent changes and is reproduced here with their permission.