tag:theconversation.com,2011:/id/topics/tobacco-control-3874/articlesTobacco control – The Conversation2024-01-23T19:00:02Ztag:theconversation.com,2011:article/2214122024-01-23T19:00:02Z2024-01-23T19:00:02ZFor the new vape laws to succeed, these 3 things need to happen – or users may look to the illicit market<figure><img src="https://images.theconversation.com/files/570782/original/file-20240123-15-tpau1a.jpg?ixlib=rb-1.1.0&rect=17%2C511%2C5973%2C3476&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/a-woman-sitting-on-a-bench-next-to-a-man-IktGJT61bG4">Ernst Gunther Krause/Unsplash</a></span></figcaption></figure><p>This year, the Australian government will progressively <a href="https://theconversation.com/from-today-new-regulations-make-it-harder-to-access-vapes-heres-whats-changing-218816">ban</a> the retail sale of all e-cigarettes, known as vapes. Vapers will <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/next-steps-on-vaping-reforms?language=en">only be allowed</a> to use nicotine vapes that comply with <a href="https://www.tga.gov.au/products/unapproved-therapeutic-goods/vaping-hub/reforms-regulation-vapes">Therapeutic Goods Administration</a> (TGA) product requirements – and only to help them quit or manage their nicotine dependence, if prescribed by a doctor and dispensed by a pharmacy.</p>
<p>This will be <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/next-steps-on-vaping-reforms?language=en">accompanied by</a> increased funding for law enforcement to prevent illegal importation of vapes, a public education campaign about the risks of vaping, and greater efforts to encourage smokers to only obtain their vapes on prescription.</p>
<p>But for the scheme to be successful, three things need to happen: vaping products that vapers will use need to be available, GPs need to be willing to write prescriptions, and pharmacies need to be able to meet the demand. None of these are guaranteed. </p>
<p>Failure to do so could see some people continue to use the illicit market for vapes, or to switch to traditional cigarettes. </p>
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Read more:
<a href="https://theconversation.com/from-today-new-regulations-make-it-harder-to-access-vapes-heres-whats-changing-218816">From today, new regulations make it harder to access vapes. Here's what's changing</a>
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<h2>The previous vape policy failed</h2>
<p>The new policy tightens the enforcement of a <a href="https://link.springer.com/chapter/10.1007/978-3-031-23658-7_1#Sec5">retail sales ban on vapes containing nicotine</a> first introduced in <a href="https://www.aph.gov.au/DocumentStore.ashx?id=b57abf1c-0e4f-49a5-a3a3-2bb02ea76bf3&subId=401164">2011</a>. This only allowed smokers to use nicotine vapes if they had been approved for smoking cessation (quitting) by the TGA and were prescribed by a doctor to help them quit smoking. </p>
<p>The TGA’s expectation was that nicotine vapes would eventually be produced that would be approved for prescription. When no vapes had been approved by 2021, the TGA <a href="https://www.tga.gov.au/resources/publication/scheduling-decisions-final/notice-final-decision-amend-current-poisons-standard-nicotine">reclassified nicotine</a> to allow doctors to prescribe unapproved nicotine vapes.</p>
<p>But these policies didn’t meet their objectives. <a href="https://oia.pmc.gov.au/sites/default/files/posts/2024/01/Impact%20Analysis%20-%20Proposed%20reforms%20to%20the%20regulation%20of%20vapes.PDF">Fewer than 10% of vapers</a> obtained a prescription.</p>
<p>The TGA’s <a href="https://oia.pmc.gov.au/sites/default/files/posts/2024/01/Impact%20Analysis%20-%20Proposed%20reforms%20to%20the%20regulation%20of%20vapes.PDF">impact assessment</a> of the 2021 policy shows it failed to prevent vaping among Australian youth or give smokers legal access to vapes. This was in large part because vape retailers illegally sold nicotine vapes as nicotine-free products (which were not banned) and sold colourful, flavoured disposable vapes that appealed to young people.</p>
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<img alt="Colourful vapes in a shop" src="https://images.theconversation.com/files/570790/original/file-20240123-27-bz731n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/570790/original/file-20240123-27-bz731n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/570790/original/file-20240123-27-bz731n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/570790/original/file-20240123-27-bz731n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/570790/original/file-20240123-27-bz731n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/570790/original/file-20240123-27-bz731n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/570790/original/file-20240123-27-bz731n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Retailers illegally sold nicotine vapes as ‘nicotine-free’ products.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/man-in-black-long-sleeve-shirt-holding-black-dslr-camera-hVcmxpYg1Gc">e Liquids UK/Unsplash</a></span>
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<p>By the end of 2023, an <a href="https://oia.pmc.gov.au/sites/default/files/posts/2024/01/Impact%20Analysis%20-%20Proposed%20reforms%20to%20the%20regulation%20of%20vapes.PDF">estimated</a> 1.3 million Australian adults were using vapes containing nicotine. The largest uptake was among young adults aged 18 to 24 and there was a worrying uptake among young people aged 14 to 17. More than <a href="https://oia.pmc.gov.au/sites/default/files/posts/2024/01/Impact%20Analysis%20-%20Proposed%20reforms%20to%20the%20regulation%20of%20vapes.PDF">90% of vapes</a> were obtained illegally from retail vape stores and via internet sales.</p>
<h2>What are the new rules, and what are their aims?</h2>
<p>From January 1, the importation of disposable vapes <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/next-steps-on-vaping-reforms?language=en">is banned</a>. </p>
<p>From March, there will be a <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/next-steps-on-vaping-reforms?language=en">complete ban</a> on the import of non-therapeutic vape products. Importers of therapeutic vapes will need a licence and permit from the government’s Office of Drug Control to import them. </p>
<p>The government will <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/next-steps-on-vaping-reforms?language=en">later set product standards</a> that limit flavours, reduce permissible nicotine concentrations and require pharmaceutical packaging of therapeutic vapes.</p>
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Read more:
<a href="https://theconversation.com/my-teen-is-addicted-to-vaping-how-can-i-help-them-quit-and-manage-their-withdrawal-symptoms-208586">My teen is addicted to vaping. How can I help them quit and manage their withdrawal symptoms?</a>
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<p>The policy <a href="https://oia.pmc.gov.au/sites/default/files/posts/2024/01/Impact%20Analysis%20-%20Proposed%20reforms%20to%20the%20regulation%20of%20vapes.PDF">aims</a> to reduce adolescent vaping by 2026 while allowing adult smokers to use vapes for quitting and managing nicotine dependence, by making them easier to access. </p>
<p>But there are major challenges in achieving these goals. </p>
<h2>1. Enough therapeutic products</h2>
<p>The TGA will need to ensure there are enough products that meet their product standards and that vapers will use. </p>
<p>It’s unclear how vape producers will be encouraged to notify the TGA that their device meets standards and whether vapers will be interested in using them. </p>
<p>However, vapes exist with specified nicotine levels that could be plain-packaged, if required.</p>
<h2>2. Doctors will need to prescribe them</h2>
<p>The new regulations allow any medical or nurse practitioner to prescribe nicotine vapes for smoking cessation and to manage nicotine addiction. </p>
<p>Given the existing <a href="https://oia.pmc.gov.au/sites/default/files/posts/2024/01/Impact%20Analysis%20-%20Proposed%20reforms%20to%20the%20regulation%20of%20vapes.PDF">low uptake of vape prescribing</a> and strong discouragement from the <a href="https://www.ama.com.au/qld/news/Vaping-package-good-step-in-nicotine-control#:%7E:text=%E2%80%9CThere%20is%20little%20evidence%20to,use%20as%20a%20cessation%20aid">Australian Medical Association</a> and <a href="https://www.racp.edu.au/docs/default-source/advocacy-library/policy-on-electronic-cigarettes.pdf">medical colleges</a>, more medical practitioners will need to be persuaded to prescribe vapes. </p>
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<img alt="Doctor writes prescription" src="https://images.theconversation.com/files/570792/original/file-20240123-17-qtktw9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/570792/original/file-20240123-17-qtktw9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/570792/original/file-20240123-17-qtktw9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/570792/original/file-20240123-17-qtktw9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/570792/original/file-20240123-17-qtktw9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/570792/original/file-20240123-17-qtktw9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/570792/original/file-20240123-17-qtktw9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Uptake of vape prescribing has been low.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-patient-consulting-room-gp-surgery-2367985555">Stephen Barnes/Shutterstock</a></span>
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<p>GP guidelines for quitting recommend prescribing nicotine gum and patches, and vapes only if these products are unsuccessful. However, a <a href="https://pubmed.ncbi.nlm.nih.gov/38189560/">Cochrane review</a> of clinical trials found vapes were more effective for smoking cessation than nicotine gum and patches.</p>
<h2>3. Pharmacies need to dispense them</h2>
<p>There must be enough pharmacies prepared to dispense vapes. Pharmacy organisations are <a href="https://www.psa.org.au/nicotine-vaping-product-access-changes-coming/">cautiously supportive of the new regulations</a> but it’s unclear how many pharmacies will provide vapes. This may depend, in part, on demand for these products. </p>
<h2>Risks of the illicit market</h2>
<p>All of these challenges need to be met in two years. Failure to achieve these aims will sustain the illicit market for vapes. </p>
<p>Vapers who are unconcerned about the possibility of arrest for possessing vapes without a prescription (a <a href="https://www.criminaldefencelawyers.com.au/blog/is-vaping-illegal-in-australia/?utm_source=Mondaq&utm_medium=syndication&utm_campaign=LinkedIn-integration">criminal offence</a> in most states) may continue to use the illicit market.</p>
<p>Australian Border Force officials <a href="https://www.smh.com.au/politics/federal/smoke-alarm-warning-to-border-force-it-won-t-stop-vape-black-market-20240101-p5eujs.html">have conceded</a> they will not be able to prevent the illicit importation of vaping devices. </p>
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Read more:
<a href="https://theconversation.com/tiktok-promotes-vaping-as-a-fun-safe-and-socially-accepted-pastime-and-omits-the-harms-203423">TikTok promotes vaping as a fun, safe and socially accepted pastime – and omits the harms</a>
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<p>There is also a risk some vapers will switch to cigarettes which, while expensive, are readily available. Vapes are not without harm, but toxicological analyses <a href="https://respiratory-research.biomedcentral.com/articles/10.1186/s12931-021-01737-5">conclude</a> they are <a href="https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html">less harmful</a> than conventional cigarettes.</p>
<h2>What if the vape regulations fail?</h2>
<p>If the vape laws aren’t successful, regulators must find another way to meet the policy’s goals of minimising youth vaping and reducing the size of the illicit vaping market. </p>
<p>One way would be to allow the sale of approved vapes to adult smokers under much tighter regulations than apply to cigarettes. This could mean banning disposable vapes and restricting sales of other vapes to licensed tobacconists on the condition that they will lose their licence if they sell to youth. This could be enforced by requiring the installation of CCTV in stores, as occurs in US cannabis retail outlets. </p>
<p>This alternative model could include many of the other regulations proposed: only allowing approved vaping devices, plain packaging, flavour restrictions and no advertising. But this <a href="https://onlinelibrary.wiley.com/doi/10.1111/dar.13663">model</a> wouldn’t require a doctor’s prescription or restrict dispensing to pharmacies.</p><img src="https://counter.theconversation.com/content/221412/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Wayne Hall has been a paid advisor to the Therapeutic Goods Administration on the safety and effectiveness of medical cannabis (2017-2019) and was a member of Australian Advisory Council on Medicinal Uses of Cannabis, Commonwealth Department of Health, February 2017-2021. He has advised the World Health Organization on the health effects of cannabis, 2019-2023. He has not received any funding from the alcohol, pharmaceutical, tobacco or e-cigarette industries. His past research on tobacco related topics was funded by the National Health and Medical Research Council. The opinions expressed in this article are those of the author and do not necessarily reflect the view of the organisation where he works or its funders.</span></em></p>If the scheme isn’t successful, some people may continue using illicit vapes, or to switch to traditional cigarettes.Wayne Hall, Emeritus Professor, The National Centre for Youth Substance Use Research, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2188162023-12-31T20:28:06Z2023-12-31T20:28:06ZFrom today, new regulations make it harder to access vapes. Here’s what’s changing<figure><img src="https://images.theconversation.com/files/565086/original/file-20231212-23-grq40b.jpg?ixlib=rb-1.1.0&rect=5%2C1988%2C3946%2C3443&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/man-in-gray-sweater-smoking-cigarette-sitting-on-bench-during-daytime-3athPFPd5rs">Ryan Grice/Unsplash</a></span></figcaption></figure><p>This year the Australian government is introducing a <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/next-steps-on-vaping-reforms?language=en">series of measures</a> to restrict the availability of vapes, starting today.</p>
<p>The new reforms address loopholes in the current laws that allow easy access to highly addictive, flavoured, cheap, and harmful vaping products that are <a href="https://theconversation.com/tiktok-promotes-vaping-as-a-fun-safe-and-socially-accepted-pastime-and-omits-the-harms-203423">marketed to kids</a>. </p>
<p>Vaping products will still be available through a prescription for anyone using them to quit smoking. But the Therapeutic Goods Administration will <a href="https://www.tga.gov.au/news/media-releases/new-regulations-place-stronger-controls-importation-manufacture-and-supply-vapes">tightly regulate</a> prescription-only vapes.</p>
<p>So what are the new regulations? And why are they needed? </p>
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Read more:
<a href="https://theconversation.com/whats-in-vapes-toxins-heavy-metals-maybe-radioactive-polonium-210462">What's in vapes? Toxins, heavy metals, maybe radioactive polonium</a>
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<h2>What was wrong with the previous regulations?</h2>
<p>Before the 2024 rule changes, vaping products imported and sold in Australia were required to be nicotine-free, unless accessed through a pharmacy with a prescription from a qualified health professional. </p>
<p>Individual users were also allowed to import nicotine-vapes from overseas through the <a href="https://www.tga.gov.au/products/personal-importation-scheme">Personal Importation Scheme</a>, provided they had a valid prescription. </p>
<p>The vaping industry – including manufacturers, importers and retailers – exploited these loopholes and openly sold <a href="https://www.health.nsw.gov.au/tobacco/Publications/e-cigarette-analysis-project-summary-report.pdf">products containing nicotine</a> to young people by falsely claiming the products were “nicotine-free”. </p>
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<p>But the only way to tell the difference between a nicotine and nicotine-free vape is to test it in a lab – a time consuming and expensive endeavour, given the high volume of products imported. </p>
<p>So enforcing the nicotine/nicotine-free standards essentially proved <a href="https://www.theguardian.com/australia-news/2023/nov/29/nsw-vape-sales-retailers-increase-government-ban-2023">near impossible</a> against an industry determined to addict a new generation of users.</p>
<h2>So what’s changing?</h2>
<p>The new laws help tidy up the confusion and make the rules much clearer and easier to enforce. </p>
<p>They also address the ready access to vapes, which is the single <a href="https://theconversation.com/we-asked-over-700-teens-where-they-bought-their-vapes-heres-what-they-said-190669">biggest challenge</a> to preventing young people from vaping.</p>
<p>The regulatory changes will be rolled out in three phases:</p>
<h2>1. Importation ban</h2>
<p>The first phase, being implemented from today, includes a ban on the importation of all disposable, single-use vapes. These are the products that are <a href="https://www.cancercouncil.com.au/wp-content/uploads/2023/10/Gen-Vape-W4-Infographic-National.pdf">most popular with young people</a> and come in a variety of flavours, including fruit, confectionery, cocktails and tobacco. </p>
<p>Single-use, disposable vapes cannot be refilled, but <a href="https://www.health.nsw.gov.au/tobacco/Pages/vaping-types.aspx">come in a wide range</a> of sizes, from a few hundred of puffs, to upwards of 10,000 puffs. </p>
<p>Disposable vapes have flooded into Australia and fuelled the explosive rise in vape use among teens and young adults.</p>
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<img alt="Vape liquids in a shop" src="https://images.theconversation.com/files/565088/original/file-20231212-17-1bwxdr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/565088/original/file-20231212-17-1bwxdr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=480&fit=crop&dpr=1 600w, https://images.theconversation.com/files/565088/original/file-20231212-17-1bwxdr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=480&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/565088/original/file-20231212-17-1bwxdr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=480&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/565088/original/file-20231212-17-1bwxdr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=603&fit=crop&dpr=1 754w, https://images.theconversation.com/files/565088/original/file-20231212-17-1bwxdr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=603&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/565088/original/file-20231212-17-1bwxdr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=603&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Disposable vapes come in a range of flavours that appeal to young people.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/woman-in-black-shirt-standing-in-front-of-store-shelf-8RN9UZeL-fo">E-Liquids UK/Unsplash</a></span>
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<p>The importation of all other vapes, including refillable products, will be banned from March 1 2024, unless importers hold a licence and permit from the <a href="https://www.odc.gov.au/">Office of Drug Control</a> to lawfully import vapes. These legally imported vapes will only be sold in pharmacies to users with a prescription. </p>
<p>The Personal Importation Scheme allowance for vapes will also end on March 1 2024, meaning all vape users must access vaping products from a pharmacy in Australia.</p>
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Read more:
<a href="https://theconversation.com/tga-review-strengthens-case-for-much-tighter-vape-restrictions-at-the-border-202506">TGA review strengthens case for much tighter vape restrictions at the border</a>
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<p>This initial phase, while effectively stopping illegal vapes from coming in to Australia, doesn’t address the high volume of product that is already here. Retailers will be able to continue to sell their existing stock of “nicotine-free” vapes. But as we know, these products often <a href="https://www.tga.gov.au/news/media-releases/infringement-notices-totalling-588840-issued-three-sydney-based-tsg-stores-and-jaradat-and-sabbagh-group-pty-ltd">do contain nicotine</a>. </p>
<h2>2. Domestic manufacture and sales ban</h2>
<p>The next phase of reforms, expected to come into effect in late 2024, will eliminate the retail sale of all types of vaping products, regardless of their claimed nicotine content.</p>
<p>This second phase will include a ban on the manufacture, supply, advertising and commercial possession of vapes that fall outside of the prescription framework. </p>
<p>These changes will require amendments to the <a href="http://www6.austlii.edu.au/cgi-bin/viewdb/au/legis/cth/consol_act/tga1989191/">Therapeutic Goods Act 1989</a>, and will likely be introduced in Autumn 2024 for federal Parliament’s consideration, but the exact date is yet to be set.</p>
<h2>3. Prescription access</h2>
<figure class="align-center ">
<img alt="GP listens to patient" src="https://images.theconversation.com/files/565089/original/file-20231212-29-grq40b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/565089/original/file-20231212-29-grq40b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/565089/original/file-20231212-29-grq40b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/565089/original/file-20231212-29-grq40b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/565089/original/file-20231212-29-grq40b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/565089/original/file-20231212-29-grq40b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/565089/original/file-20231212-29-grq40b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Vapes will only be available on prescription.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/female-consultant-meeting-teenage-patient-284516786">Shutterstock</a></span>
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<p>The prescription access to vapes for therapeutic purposes is also being changed to allow access to products that meet a quality standard. </p>
<p>From today, all medical and nurse practitioners will now be able to prescribe therapeutic vapes for quitting smoking or to manage nicotine dependence. </p>
<p>Further changes that strengthen the standards for therapeutic vapes are expected to be made by March 1 2024. For example, prescription vapes will have limits on the amount of nicotine, the types of flavours permitted, and be in standardised medical-style packaging. </p>
<h2>What do the changes mean for vape users?</h2>
<p>Vapes for therapeutic purposes will continue to be permitted in Australia and more medical professionals will be able to prescribe them. Prior to 2024, only select medical professionals could prescribe vapes (they had to register as an authorised prescriber). This is being widened to ensure the prescription model works as intended. </p>
<p>While vaping products will be available by prescription it’s important to know they <a href="https://www.tga.gov.au/resources/resource/guidance/nicotine-vaping-products-information-prescribers">remain unapproved medicines</a> that have not been subjected to the same rigorous safety and effectiveness testing as other evidence-based quit smoking aids. </p>
<p>If you’re thinking of quitting smoking (or quitting vaping), get support by talking to your doctor, calling the Quitline (13 7848), or accessing <a href="https://www.icanquit.com.au/">help online</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/my-teen-is-addicted-to-vaping-how-can-i-help-them-quit-and-manage-their-withdrawal-symptoms-208586">My teen is addicted to vaping. How can I help them quit and manage their withdrawal symptoms?</a>
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</em>
</p>
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<img src="https://counter.theconversation.com/content/218816/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Becky Freeman is an Expert Advisor to the Cancer Council Tobacco Issues Committee and a member of the Cancer Institute Vaping Communications Advisory Panel. These are unpaid roles. She has received relevant competitive grants that include a focus on e-cigarettes/vaping from the NHMRC, MRFF, NSW Health, the Ian Potter Foundation, VicHealth, and Healthway WA; relevant research contracts from the Cancer Institute NSW and the Cancer Council NSW; relevant personal/consulting fees from the World Health Organization, the Hong Kong Special Administrative Region Department of Health, BMJ Tobacco Control, the Heart Foundation NSW, the US FDA, the NHMRC e-cigarette working committee, NSW Health, and Cancer Council NSW; and relevant travel expenses from the Oceania Tobacco Control Conference and the Australia Public Health Association preventive health conference.</span></em></p>Vapes will be harder to access from today, but the restrictions are staged, with some due to roll out later in the year. Here’s what’s changing.Becky Freeman, Associate Professor, School of Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2034232023-05-12T02:16:09Z2023-05-12T02:16:09ZTikTok promotes vaping as a fun, safe and socially accepted pastime – and omits the harms<figure><img src="https://images.theconversation.com/files/524825/original/file-20230508-201568-n2sjkc.jpg?ixlib=rb-1.1.0&rect=80%2C152%2C2914%2C1827&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-man-smoking-electronic-cigarette-looking-579691078">Shutterstock</a></span></figcaption></figure><p>Social media platforms such as Instagram, TikTok and Facebook overwhelmingly <a href="https://www.jmir.org/2019/2/e11953/">show vaping</a> in a positive light. This messaging makes it seem that e-cigarette use is common and socially accepted. </p>
<p>Traditional tobacco advertising has been banned in Australia for decades. However, e-cigarettes are <a href="https://theconversation.com/vaping-is-glamourised-on-social-media-putting-youth-in-harms-way-159436">widely promoted</a> on social media, undoing some of the positive work of previous decades.</p>
<p>Most platforms have <a href="https://www.tiktok.com/community-guidelines?lang=en">content policies</a> that expressly prohibit the promotion of tobacco product use, including e-cigarettes. But our <a href="https://www.mdpi.com/1660-4601/20/10/5761">new research</a>, published this week, shows these policies are <a href="https://tobaccocontrol.bmj.com/content/early/2022/11/03/tc-2022-057348">routinely violated</a> with little or no consequences.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/vaping-is-glamourised-on-social-media-putting-youth-in-harms-way-159436">Vaping is glamourised on social media, putting youth in harm's way</a>
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<hr>
<h2>Positive videos result in more vaping</h2>
<p>E-cigarette <a href="https://moqc.org/wp-content/uploads/2017/08/Surgeon-General-Report_Use-of-E-cigarettes-Among-Youth-and-Young-Adults-2016.pdf">use</a> by young people, <a href="https://theconversation.com/we-asked-over-700-teens-where-they-bought-their-vapes-heres-what-they-said-190669">including in Australia</a>, is rapidly growing. So is evidence of the harmful <a href="https://openresearch-repository.anu.edu.au/handle/1885/262914">health effects of e-cigarettes</a>. </p>
<p>Positive social media messages around vaping may particularly impact young people, who are the most frequent users of social media. In some cases, these messages have even been shown to <a href="https://theconversation.com/e-cigarette-maker-juul-settled-a-lawsuit-over-its-practice-of-targeting-teens-through-social-media-parties-and-models-heres-why-the-company-is-paying-438-5-million-to-dozens-of-states-190399">blatantly target</a> teens. </p>
<p><a href="https://www.sciencedirect.com/science/article/pii/S221133552200362X?via%3Dihub">Research shows</a> young people who view social media posts featuring e-cigarettes are more likely to vape and to view e-cigarettes positively. This is true of both e-cigarette advertising and user-generated content, with creators <a href="https://www.mdpi.com/1660-4601/19/3/1820">effectively doing the marketing job</a> for e-cigarette companies.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1632466603437858817"}"></div></p>
<h2>TikTok emphasises tricks and downplays harms</h2>
<p>In our recently published study, we looked at the ways e-cigarettes are being advertised and promoted on TikTok. We analysed 264 English language user-generated e-cigarette videos and evaluated them against TikTok’s own content policy in February 2022.</p>
<p>We found most of the videos (98%) portrayed e-cigarettes positively. </p>
<p>More than one-quarter of the videos clearly violated TikTok’s content policy and promoted vaping products for purchase. </p>
<p>Few videos contained health warnings. Only 2% of posts referenced vape or nicotine addiction. </p>
<p>A small number of posts referred to public health professionals or commented on e-cigarette regulation. These posts were comparatively less popular, receiving a smaller proportion of views and likes. </p>
<p>Half the videos referred to a vaping community. These posts were slightly more popular than those that didn’t refer to a shared identity. This may act to <a href="https://tobaccocontrol.bmj.com/content/32/2/251">shape norms</a> around e-cigarette use and increase the perception that vaping is socially accepted. </p>
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<p>Popular posts also included references to vape tricks (such as creating shapes from exhaled aerosol), with <a href="https://www.jahonline.org/article/S1054-139X(17)30215-X/fulltext">early research</a> showing adolescents often identified vaping tricks as the reason they started using e-cigarettes. Posts also used humour, which is an <a href="https://tobaccocontrol.bmj.com/content/32/2/251">effective tool</a> to reach young social media users.</p>
<p>Videos that violated content policy often provided details on how and where to purchase e-cigarette products. This included providing links to online retailers and to other social media accounts. </p>
<p>The promotion of offers such as giveaways and sale prices were common, in direct violation of content policy. Many posts also provided product reviews. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/vaping-and-behaviour-in-schools-what-does-the-research-tell-us-204794">Vaping and behaviour in schools: what does the research tell us?</a>
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<hr>
<h2>So what needs to happen?</h2>
<p>We can’t rely on platforms to develop and enforce content policy. Social media policies are commonly violated and there are <a href="https://pubmed.ncbi.nlm.nih.gov/34907688/">no major consequences</a> – the platforms themselves decide the consequences for breaches. </p>
<p>This is a problem because social media platforms have a clear financial incentive not to punish people who breach their policies.</p>
<p>The federal government’s <a href="https://www.health.gov.au/sites/default/files/2023-05/tackling-smoking-and-vaping-and-improving-cancer-outcomes-budget-2023-24.pdf">recent strong position</a> to stamp out recreational vaping among young people through regulations, enforcement, education, plain packaging and a ban on flavourings is welcomed. </p>
<p>However, this did not include clamping down on e-cigarette advertising, promotion and sponsorship on social media, which is also <a href="https://apps.who.int/gb/fctc/PDF/cop6/FCTC_COP6(9)-en.pdf">clearly needed</a>. </p>
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<p>Emphasis needs to be placed on enforcement of policies. This must include requiring social media platforms to report on how they’re ensuring regulations are being upheld.</p>
<p>Current policies and moderation processes are insufficient in restricting the spread of pro e-cigarette content on TikTok. This is exposing young social media users to e-cigarette use. There needs to be greater regulation of e-cigarette content and its promotion, to prevent future uptake and harm to young people.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-can-i-help-my-teen-quit-vaping-201558">How can I help my teen quit vaping?</a>
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</em>
</p>
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<img src="https://counter.theconversation.com/content/203423/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jonine Jancey receives funding from Healthway and is a Board member of the Australian Council on Smoking and Health.</span></em></p><p class="fine-print"><em><span>Renee Carey does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Social media platforms have policies prohibiting the promotion of tobacco products, including vaping. But these policies are routinely violated, with little or no consequences.Renee Carey, Senior Research Fellow, Curtin UniversityJonine Jancey, Academic and Director Collaboration for Evidence, Research and Impact in Public Health, Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2053822023-05-11T03:51:52Z2023-05-11T03:51:52ZWe worked out how many tobacco lobbyists end up in government, and vice versa. It’s a lot<figure><img src="https://images.theconversation.com/files/525266/original/file-20230510-45636-oxeu0l.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C561&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/unrecognizable-slender-caucasian-business-woman-manager-1408880285">Shutterstock</a></span></figcaption></figure><p>We’ve just revealed the extent of the close relationship between tobacco lobbyists and government, in the first Australian study of its kind.</p>
<p>Our study, <a href="https://doi.org/10.17061/phrp33122305">published today</a>, found about half of people involved in tobacco lobbying held positions in Australian governments before or after working for the tobacco industry.</p>
<p>This “<a href="https://exposetobacco.org/news/revolving-doors/">revolving door</a>” between tobacco lobbyists and government is a key political lobbying mechanism to influence public health policy.</p>
<p>So we urgently need to strengthen the rules and legislation around lobbying if we are to avoid industry influencing policies on issues such as tobacco control and vaping.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1656441490950742021"}"></div></p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-revolving-door-why-politicians-become-lobbyists-and-lobbyists-become-politicians-64237">The revolving door: why politicians become lobbyists, and lobbyists become politicians</a>
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<hr>
<h2>What we did and what we found</h2>
<p>We gathered information from sources including federal, state and territory government lobbyist registers, social networking platform LinkedIn, and Australian news media.</p>
<p>We identified 56 lobbyists representing tobacco companies (via lobbyist registers and archives) and another 73 current and former in-house tobacco lobbyists (via other means).</p>
<p>We found 48% of in-house tobacco company lobbyists and 55% of lobbyists acting on behalf of tobacco companies held positions in Australian state or federal governments before or after working for the tobacco industry.</p>
<p>Senior government roles included members of parliament, senators, chief or deputy chiefs of staff, and senior ministerial advisors.</p>
<p>Around half of the lobbyists had moved into or out of their government roles within a year of working for a tobacco company (56%) or as a lobbyist for one (48%).</p>
<p>We also documented how tobacco companies use third-party allies to indirectly lobby government – a form of lobbying that is poorly recorded on lobbyist registers and is not easily tracked. </p>
<p>For example, the Australian Retail Vaping Industry Association was created with funding <a href="https://www.afr.com/policy/health-and-education/the-secret-money-trail-behind-vaping-20210217-p573bi">from global tobacco company</a> Philip Morris International and lobbied to weaken Australian vaping regulations.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/politicians-who-become-lobbyists-can-be-bad-for-australians-health-124078">Politicians who become lobbyists can be bad for Australians' health</a>
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<hr>
<h2>Why is this a worry?</h2>
<p>We’ve long suspected there has been a “revolving door” between government and the tobacco industry – whereby tobacco companies recruit people who have previously held senior government roles to lobby for them.</p>
<p>It’s a tactic common <a href="https://www.phrp.com.au/issues/september-2019-volume-29-issue-3/the-revolving-door-between-government-and-the-alcohol-food-and-gambling-industries-in-australia/">in the gambling, alcohol and food industries</a>.</p>
<p>The aim is to learn about upcoming policies affecting their industries, and develop relationships with people of influence, with a view to shaping policy that favours their interests.</p>
<p>Our study, published today in the Sax Institute’s peer-reviewed journal <a href="https://doi.org/10.17061/phrp33122305">Public Health Research and Practice</a>, systematically catalogues for the first time how widespread this practice is.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-to-deal-with-fossil-fuel-lobbying-and-its-growing-influence-in-australian-politics-188515">How to deal with fossil fuel lobbying and its growing influence in Australian politics</a>
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<hr>
<h2>Out of sight</h2>
<p>The movement of key people between government and tobacco industry roles without adequate transparency provides potential opportunities to influence policymaking out of sight. </p>
<p>This can lead to delayed, weakened, or suppressed implementation of tobacco control and anti-vaping reforms. </p>
<p>In Australia, tobacco industry interference tactics largely hinge on the industry’s new product pipeline – e-cigarettes (vaping products). </p>
<p>Examples of industry lobbying efforts to legalise <a href="https://www.smh.com.au/business/consumer-affairs/ultimate-hypocrisy-who-is-really-behind-the-pro-vape-ad-campaign-20230328-p5cw25.html">the retail sale of nicotine vaping products</a> recently include lobbying the federal government <a href="https://tobaccocontrol.bmj.com/content/31/3/458">through submissions to legislative reviews</a>, participating in inquiry hearings, making political donations, meeting privately with parliamentarians, funding third parties to lobby on their behalf, and <a href="https://www.abc.net.au/news/science/2020-01-10/tobacco-industry-sought-vaping-meetings-with-pm-and-cabinet/11855264">sending unsolicited letters to ministers</a>.</p>
<p>There is no suggestion any individual or organisation acted illegally, contravened employment guidelines or principles, or otherwise acted improperly – including in the performance of lobbying duties. </p>
<p>However, the “revolving door” is important for tobacco companies as it provides opportunities to influence policymaking out of public sight.</p>
<p><a href="http://transparency.eu/wp-content/uploads/2017/01/Access-all-areas.pdf">Examples from overseas</a> suggest the prospect of a lucrative future career in the private sector can be enough to influence decisions that favour industry while still in office.</p>
<p>This can potentially <a href="https://law.adelaide.edu.au/ua/media/1773/Regulating%20the%20Influencers%20The%20Evolution%20of%20Lobbying%20Regulation%20in%20Australia.pdf">undermine</a> the quality and integrity of Australia’s democratic system.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/lobbying-regulations-are-vital-to-any-well-functioning-democracy-its-time-nz-got-some-203404">Lobbying regulations are vital to any well functioning democracy – it's time NZ got some</a>
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</p>
<hr>
<h2>What can we do about it?</h2>
<p><strong>1. Greater public disclosure</strong></p>
<p>There needs to be more extensive public disclosure of all tobacco company employees and lobbyists – acting directly or via third-party allies. This information should be added to existing government registers, and also include detailed updates of activities and meetings.</p>
<p><strong>2. Enforce ‘cooling off’ periods</strong></p>
<p>We need to extend and enforce “cooling off” periods – the minimum time required between switching from public to the private sector. These range from 12 to 18 months, depending on the role held in government. But our study showed these cooling off periods are not being enforced, and there are no serious sanctions.</p>
<p><strong>3. Update and enforce the law</strong></p>
<p>Transparency and integrity legislation must be updated and enforced. Adopting policies in line with international best practices, <a href="https://democracywatch.ca/reasons-why-a-long-cooling-off-period-4-years-or-more-prohibiting-lobbying-after-significant-political-activity-is-entirely-charter-compliant/">such as in Canada</a>, to safeguard against the influence of tobacco companies in Australian policy making.</p>
<p><strong>4. Recognise the ‘revolving door’</strong> </p>
<p>We need to recognise “revolving door” tactics as as part of the implementation of <a href="https://fctc.who.int/publications/m/item/guidelines-for-implementation-of-article-5.3">the WHO Framework Convention on Tobacco Control</a>. The Australian government is a signator to this convention. It has committed to protecting public health from the vested interests of the tobacco industry <a href="https://www.health.gov.au/resources/publications/guidance-for-public-officials-on-interacting-with-the-tobacco-industry">by publishing guidance</a> for public officials on interacting with the tobacco industry. However, lobbying through the “revolving door” is not explicitly recognised or outlined in this guidance.</p>
<hr>
<p><em>We would like to acknowledge our co-authors on the study, Melissa Jones and Kylie Lindorff.</em></p><img src="https://counter.theconversation.com/content/205382/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Becky Freeman is an Expert Advisor to the Cancer Council Tobacco Issues Committee and a member of the Cancer Institute Vaping Communications Advisory Panel. These are unpaid roles. She has received relevant competitive grants that include a focus on e-cigarettes/vaping from the NHMRC, MRFF, NSW Health, the Ian Potter Foundation, VicHealth, and Healthway WA; relevant research contracts from the Cancer Institute NSW and the Cancer Council NSW; relevant personal/consulting fees from the World Health Organization, the Hong Kong Special Administrative Region Department of Health, BMJ Tobacco Control, the Heart Foundation NSW, the US FDA, the NHMRC e-cigarette working committee, NSW Health, and Cancer Council NSW; and relevant travel expenses from the Oceania Tobacco Control Conference and the Australia Public Health Association preventive health conference.</span></em></p><p class="fine-print"><em><span>Christina Watts has received funding from the Australian Government Department of Health and Aged Care, NSW Ministry of Health, Cancer Council NSW, Cancer Institute NSW and the Minderoo Foundation.</span></em></p>About half of people involved in tobacco lobbying held positions in Australian governments before or after working for the tobacco industry.Becky Freeman, Associate Professor, School of Public Health, University of SydneyChristina Watts, Research Fellow, The Daffodil Centre, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2048122023-05-03T05:13:19Z2023-05-03T05:13:19ZCan vaping help people quit smoking? It’s unlikely<figure><img src="https://images.theconversation.com/files/523954/original/file-20230503-14-m0t8hk.jpg?ixlib=rb-1.1.0&rect=81%2C63%2C5925%2C3944&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/many-different-disposable-ecigarettes-hand-delicious-2049512471">Shutterstock</a></span></figcaption></figure><p>Australian Health Minister Mark Butler has announced a <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/taking-action-on-smoking-and-vaping?language=en">major policy shift on vaping</a>. Its two primary objectives are to make it harder for children and non-smokers to access vapes and to allow people trying to quit smoking to access nicotine vapes with a prescription. </p>
<p>Vapes are unquestionably popular, with many who vape saying they are trying to quit or to cut down on cigarettes. “Recreational” vapers of any age with no interest in quitting will find themselves frozen out.</p>
<p>But can vapes actually help significant numbers of people quit smoking? The evidence suggests it’s unlikely. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/a-potted-history-of-smoking-and-how-were-making-the-same-mistakes-with-vaping-200708">A potted history of smoking, and how we're making the same mistakes with vaping</a>
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<hr>
<h2>Myth of the ‘hardened smokers’</h2>
<p>First, let’s bust a widely believed myth. With smoking at an <a href="https://www.health.gov.au/sites/default/files/2023-05/national-tobacco-strategy-2023-2030.pdf">all time low</a>, some experts argue today’s smokers are the die-hard addicts: frequently relapsing smokers who just can’t quit. </p>
<p>Whenever this hypothesis has been tested it has been found wanting. In nations where smoking prevalence has fallen most, we would expect (if the hypothesis was true) that indicators of hardened smokers (such as average number of cigarettes smoked per day) would be rising because the remaining smokers would be over-represented by heavy, addicted smokers.</p>
<p>But according to <a href="https://pubmed.ncbi.nlm.nih.gov/30868166/">a 2020 review of 26 studies</a>:</p>
<blockquote>
<p>Some have argued that a greater emphasis on harm reduction or intensive treatment approaches is needed because remaining smokers are those who are less likely to stop with current methods. This review finds no or little evidence for this assumption.</p>
</blockquote>
<p>In other words, there is no evidence long-term smokers are impervious to the suite of tobacco control policies and campaigns that have driven hundreds of millions of smokers around the world to quit. </p>
<figure class="align-center ">
<img alt="Ashtray close up" src="https://images.theconversation.com/files/523958/original/file-20230503-19-71ckwh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523958/original/file-20230503-19-71ckwh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=385&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523958/original/file-20230503-19-71ckwh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=385&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523958/original/file-20230503-19-71ckwh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=385&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523958/original/file-20230503-19-71ckwh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=484&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523958/original/file-20230503-19-71ckwh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=484&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523958/original/file-20230503-19-71ckwh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=484&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The idea that ‘hardened smokers’ can’t quit is a myth.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/ashtray-full-smoked-cigarettes-extreme-close-1579956118">Shutterstock</a></span>
</figcaption>
</figure>
<h2>Vapes don’t help smokers cut back</h2>
<p>The idea that vaping helps people smoke fewer cigarettes isn’t supported by the evidence. Studies of the number of cigarettes foregone by vapers who still smoke have shown that, compared with smokers who never vape, the average daily cigarette consumption is very similar. </p>
<p>Data from 2019 from the United Kingdom government’s annual <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/methodologies/opinionsandlifestylesurveyqmi">Opinions and Lifestyle Survey</a> also <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/drugusealcoholandsmoking/datasets/ecigaretteuseingreatbritain">show</a> the average number of cigarettes smoked daily by smokers who vape (8 a day) is almost identical to that by smokers who have never vaped (8.1 a day).</p>
<p><a href="https://bmjopen.bmj.com/content/8/6/e016046">A 2018 paper</a> considered the surge in e-cigarette use in England and whether this was reducing the number of cigarettes being smoked at the population level across the country. The authors concluded:</p>
<blockquote>
<p>No statistically significant associations were found between changes in use of e-cigarettes […] while smoking and daily cigarette consumption. Neither did we find clear evidence for an association between e-cigarette use […] specifically for smoking reduction and temporary abstinence, respectively, and changes in daily cigarette consumption. </p>
<p>If use of e-cigarettes […] while smoking acted to reduce cigarette consumption in England between 2006 and 2016, the effect was likely very small at a population level. </p>
</blockquote>
<h2>How effective are vapes in quitting?</h2>
<p>The most recent <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010216.pub7/full">Cochrane review</a> of randomised controlled trials compared vaping with nicotine replacement therapy (such as drugs, gums and patches). It found <a href="https://profglantz.com/2022/11/21/cochrane-collaborative-concludes-e-cigs-as-medical-interventions-help-smokers-quit-again-while-continuing-to-ignoring-stronger-more-relevant-real-world-evidence-that-they-dont/">about 82%</a> of people who vape are still smoking when followed up six or more months later. </p>
<p>This was better than those using nicotine replacement therapy: 90% were still smoking.</p>
<p>Neither nicotine replacement therapy or vapes are hugely disruptive of smoking. You certainly wouldn’t be confident using a drug for any health issue that had a 82-90% failure rate. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/drugs-gums-or-patches-wont-increase-your-chances-of-quitting-89767">Drugs, gums or patches won't increase your chances of quitting</a>
</strong>
</em>
</p>
<hr>
<figure class="align-center ">
<img alt="GP listens to patient" src="https://images.theconversation.com/files/523955/original/file-20230503-26-oc0x2b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523955/original/file-20230503-26-oc0x2b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523955/original/file-20230503-26-oc0x2b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523955/original/file-20230503-26-oc0x2b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523955/original/file-20230503-26-oc0x2b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523955/original/file-20230503-26-oc0x2b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523955/original/file-20230503-26-oc0x2b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Nicotine replacement therapies aren’t very effective at helping people quit.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/female-consultant-meeting-teenage-patient-284516786">Shutterstock</a></span>
</figcaption>
</figure>
<p>Randomised controlled trials also poorly reflect the ways vapes and nicotine replacement therapy are used in the real world and aren’t representative of all smokers wanting to quit. </p>
<p>A <a href="https://pubmed.ncbi.nlm.nih.gov/21212379/">review</a> of 54 randomised controlled trials on quitting smoking, for example, found two-thirds of smokers with nicotine dependence would have been excluded from clinical trials by at least one criterion. This may result in participation biases, which reduce the applicability of the results to smokers at large, or even smokers at large who want to quit. </p>
<p>This, and <a href="https://ses.library.usyd.edu.au/bitstream/handle/2123/28576/Mass%20distraction%20with%20cover.pdf?sequence=3&isAllowed=y">other factors</a>, make randomised controlled trials likely to overestimate effectiveness, as I outline in <a href="https://ses.library.usyd.edu.au/bitstream/handle/2123/28576/Mass%20distraction%20with%20cover.pdf?sequence=3&isAllowed=y">chapter two of my book</a>. </p>
<h2>What does the real-world evidence show?</h2>
<p>The best evidence we have about how vapes perform comes from studies where large numbers of vapers are followed for several years. The <a href="https://tobaccocontrol.bmj.com/content/26/4/371">US Population Assessment of Tobacco and Health (PATH) project</a>, for example, has been collecting national cohort data on 46,000 Americans since 2013.</p>
<p>As the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6202279/pdf/nihms965122.pdf">PATH data</a> below show, when randomly selected groups of vapers are followed up at 12 months, the most common outcome is those who were smoking and vaping at the beginning of the study period will still be vaping and smoking at the end of the 12 months. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/523994/original/file-20230503-16-7qv313.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523994/original/file-20230503-16-7qv313.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=578&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523994/original/file-20230503-16-7qv313.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=578&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523994/original/file-20230503-16-7qv313.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=578&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523994/original/file-20230503-16-7qv313.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=726&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523994/original/file-20230503-16-7qv313.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=726&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523994/original/file-20230503-16-7qv313.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=726&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The most common outcome is those who were smoking and vaping at the start were still doing both 12 months later.</span>
<span class="attribution"><span class="source">Data from the US Population Assessment of Tobacco and Health (PATH) project</span></span>
</figcaption>
</figure>
<p>I’ve summarised 16 other <a href="https://simonchapman6.com/vaping-research-alerts/#smoking-cessation">reviews and expert group conclusions</a> of the evidence published since 2017. Words like “low quality”, “inconclusive”, “insufficient”, “weak”, “low level” and “limited” abound.</p>
<h2>The upshot?</h2>
<p>The prescription vapes access scheme’s most important population effect is likely to be that it will massively reduce access to vapes by children. State governments will start hitting retailers illegally selling with massive fines and Border Security will do the same with importing suppliers. </p>
<p>Taiwan fines sellers a maximum of <a href="https://en.rti.org.tw/news/view/id/2009188">US$1.65 million, with a minimum of US$330,000</a>. The current maximum fine in New South Wales is currently only A$1,600. Such a fine would barely raise dust in big retailers’ petty cash drawers.</p>
<p>Based on the research, we might expect 10-18% of vapers using the prescription scheme to quit within 12 months (with some relapse expected), but many more will <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000216">quit unassisted</a>.</p>
<p>Preventing new generations of kids from becoming addicted to nicotine and more likely to start smoking is a huge policy advance that is hugely welcome.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/vaping-and-behaviour-in-schools-what-does-the-research-tell-us-204794">Vaping and behaviour in schools: what does the research tell us?</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/204812/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Chapman does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Many people who vape saying they are trying to quit or to cut down on cigarettes.Simon Chapman, Emeritus Professor in Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2025062023-03-27T02:53:49Z2023-03-27T02:53:49ZTGA review strengthens case for much tighter vape restrictions at the border<figure><img src="https://images.theconversation.com/files/517537/original/file-20230327-14-enx712.jpg?ixlib=rb-1.1.0&rect=7%2C15%2C5306%2C3521&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/new-york-nyusaseptember-17-2019-selection-1507937528">Shutterstock</a></span></figcaption></figure><p>On Friday, the Therapeutic Goods Administration (TGA) <a href="https://consultations.tga.gov.au/medicines-regulation-division/proposed-reforms-to-the-regulation-of-nicotine-vap/">updated</a> its review of proposed reforms to the regulation of nicotine vaping products. It reported the federal government is now “actively considering” the TGA’s advice. </p>
<p>The TGA’s advice has not been released at this time, but a top-level summary of the review consultation submissions was. It restated the review’s scope, focused on changes to border controls for nicotine vaping products, minimum quality and safety standards – including the idea of categorising nicotine vaping products as therapeutic goods. </p>
<p>The update’s emphasis on enforcement and safety supports the goal to ensure nicotine vaping products are available only to people using them to try to quit smoking.</p>
<h2>Nothing is off the table</h2>
<p>Three weeks ago, all the <a href="https://www.health.gov.au/committees-and-groups/health-ministers-meeting-hmm">Australian health ministers agreed</a> to set up a working group to consider options to address the availability of all e-cigarettes, including nicotine and non-nicotine containing devices. </p>
<p>Since then, Federal Health Minister Mark Butler has been <a href="https://www.abc.net.au/news/2023-03-21/nationals-propose-easing-vaping-rules-or-adults/102122406">increasingly vocal</a> about improving border controls to enforce Australian laws that say nicotine vapes should only be available via prescription.</p>
<p>Butler says “<a href="https://markbutler.net.au/news/transcripts/radio-interview-abc-hobart-mornings-with-leon-compton-wednesday-22-march-2023/">nothing is off the table</a>” – except allowing the sale of nicotine e-cigarettes without a doctor’s prescription in retailers such as convenience stores. Currently, illicit sales of nicotine vaping products are occurring on a growing scale, with hundreds of retail outlets selling nicotine e-cigarettes in blatant breach of public health laws.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/marketers-are-targeting-teens-with-cheap-and-addictive-vapes-9-ways-to-stem-rising-rates-of-youth-vaping-198291">Marketers are targeting teens with cheap and addictive vapes: 9 ways to stem rising rates of youth vaping</a>
</strong>
</em>
</p>
<hr>
<h2>What do the consultation responses tell us?</h2>
<p>The TGA <a href="https://consultations.tga.gov.au/medicines-regulation-division/proposed-reforms-to-the-regulation-of-nicotine-vap/consultation/published_select_respondent">published almost 4,000</a> submissions. </p>
<p>They came primarily from two viewpoints. On the one hand, the majority of public health stakeholders (including non-government organisations and state and territory government health and education agencies) who called for stronger border controls. On the other, those aligned with commercial interests calling for nicotine e-cigarettes to be sold legally over the counter.</p>
<p>The TGA <a href="https://consultations.tga.gov.au/medicines-regulation-division/proposed-reforms-to-the-regulation-of-nicotine-vap/">noted a large number of submissions</a> from “the general public” appeared to be “campaign responses” calling for vaporiser nicotine to be removed from the poisons standard so it can be sold by any retailer. </p>
<p>This is a well-worn tactic used by the tobacco industry and its retailer allies – <a href="https://tobaccotactics.org/wiki/astroturfing/">orchestrate responses</a> to public consultations purporting to be the voice of the community. In reality, these represent the interests of commercial entities. And anyway, repealing the scheduling of vaporiser nicotine as a prescription-only substance <a href="https://www.tga.gov.au/resources/consultation/consultation-proposed-reforms-regulation-nicotine-vaping-products">is not within the scope</a> of the review.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/517539/original/file-20230327-18-90i7il.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="person breathes out vapour from e-cigarette" src="https://images.theconversation.com/files/517539/original/file-20230327-18-90i7il.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/517539/original/file-20230327-18-90i7il.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517539/original/file-20230327-18-90i7il.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517539/original/file-20230327-18-90i7il.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517539/original/file-20230327-18-90i7il.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517539/original/file-20230327-18-90i7il.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517539/original/file-20230327-18-90i7il.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Evidence shows few people are successfully using vapes to quit tobacco.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/new-york-nyusaseptember-17-2019-selection-1507937528">Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/a-potted-history-of-smoking-and-how-were-making-the-same-mistakes-with-vaping-200708">A potted history of smoking, and how we're making the same mistakes with vaping</a>
</strong>
</em>
</p>
<hr>
<h2>Unresolved issues</h2>
<p>Although state and territory government health and education agencies called unanimously for tighter border controls, there were varied views on how this could be achieved. </p>
<p>Some proposed the introduction of an import permit. Others <a href="https://consultations.tga.gov.au/medicines-regulation-division/proposed-reforms-to-the-regulation-of-nicotine-vap/user_uploads/tga-consultation-paper---nicotine-vaping-products---nov-22-1.pdf">suggested</a> amending customs regulations administered by the Department of Home Affairs, which would require Australian Border Force to seize nicotine vaping products imported without medical authority. Many submissions proposed extending this to non-nicotine vaping products as well.</p>
<p><a href="https://www.tobaccoinaustralia.org.au/chapter-18-e-cigarettes/18-15-position-statements">Independent health groups</a> – particularly the Cancer Council, the National Heart Foundation and the Australian Council on Smoking and Health, who were previously involved in landmark policy achievements such as plain packaging of tobacco – all supported customs seizures. </p>
<p>Based on all the evidence, including the <a href="https://onlinelibrary.wiley.com/doi/10.5694/mja2.51890">harms of vaping</a>, <a href="https://www.tobaccoinaustralia.org.au/chapter-18-e-cigarettes/18-3-extent">patterns of use</a> and current policies, this option would turn the tap off at the border. State and territory governments must also end illegal retail sales in their respective jurisdictions. This would end current exemptions for non-nicotine vaping product sales, and ensure all vaping products, regardless of claimed nicotine content, are <a href="https://www.phrp.com.au/issues/march-2023-volume-33-issue-1/reigniting-tobacco-control/">only accessed</a> through the prescription pathway. </p>
<p>The proliferation of so-called non-nicotine vaping products, many of which contain nicotine <a href="https://www.health.nsw.gov.au/tobacco/Pages/enforcement-nicotine-containing-e-cigarettes.aspx">when tested</a>, is disrupting enforcement efforts to make nicotine vaping products prescription-only. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1639188046179635200"}"></div></p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/learning-about-the-health-risks-of-vaping-can-encourage-young-vapers-to-rethink-their-habit-199557">Learning about the health risks of vaping can encourage young vapers to rethink their habit</a>
</strong>
</em>
</p>
<hr>
<h2>What happens next?</h2>
<p>It’s time for greater enforcement and regulatory reform action – not just deferral to “working groups”, “consultations” and “inquiries”. Queensland’s parliament just moved to conduct <a href="https://statements.qld.gov.au/statements/97340">another inquiry</a> of e-cigarettes, at least the fourth in Australia since 2017.</p>
<p>Soon we’ll hear what the government plans to prioritise. If the federal response to the TGA review turns out to be an import permit instead of prohibiting imports, then it must be backed with effective enforcement. Retailers are already flouting federal laws (both the poisons standard and the Therapeutic Goods Order) and state/territory public health acts by importing and selling nicotine vaping products. Without enforcement, an import permit will be just another policy instrument to be ignored.</p>
<p>Nothing turns a profit like commercialised addiction. Vaping manufacturers and retailers know this and appear determined to addict as many users as possible through increasing lawbreaking, while Australian governments “consider their options”. Not since the debut of <a href="https://tobacco.stanford.edu/about/">mass-marketing of cigarettes</a> in the 19th century has a whole population been at such risk of nicotine addiction and health harms on an industrial scale.</p>
<p>The evidence is clear. E-cigarettes are <a href="https://onlinelibrary.wiley.com/doi/10.5694/mja2.51890">harmful to health</a>, non-smoking users have a <a href="https://bmjopen.bmj.com/content/11/3/e045603">three-fold risk of smoking uptake</a>, the largest user groups are <a href="https://www.tobaccoinaustralia.org.au/chapter-18-e-cigarettes/18-3-extent">young adults aged under 25</a>, and teenagers and <a href="https://openresearch-repository.anu.edu.au/bitstream/1885/247864/1/Updated%20Evidence%20Review%20EC%20and%20Cessation%20for%20online%20publication%20210915.pdf">few people</a> are successfully using e-cigarettes to quit smoking. </p>
<p>Australian governments are clear about their shared commitment to restricting nicotine vaping products to a prescription pathway. Now they need to commit to action – by seizing all imported vaping products not destined for a pharmacy, and extending the current restrictions and enforcement to all vaping products.</p><img src="https://counter.theconversation.com/content/202506/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Becky Freeman is an Expert Advisor to the Cancer Council Tobacco Issues Committee and a member of the Cancer Institute Vaping Communications Advisory Panel. These are unpaid roles. She has received relevant competitive grants that include a focus on e-cigarettes/vaping from the NHMRC, MRFF, NSW Health, the Ian Potter Foundation, VicHealth, and Healthway WA; relevant research contracts from the Cancer Institute NSW and the Cancer Council NSW; relevant personal/consulting fees from the World Health Organization, the Hong Kong Special Administrative Region Department of Health, BMJ Tobacco Control, the Heart Foundation NSW, the US FDA, the NHMRC e-cigarette working committee, NSW Health, and Cancer Council NSW; and relevant travel expenses from the Oceania Tobacco Control Conference and the Australia Public Health Association preventive health conference.</span></em></p><p class="fine-print"><em><span>Paul Grogan is employed by the Daffodil Centre, a joint cancer research venture between Cancer Council NSW and the University of Sydney, which is a partner in the jointly funded GenVape research project, and which also provided modelling of smoking prevalence trends subcontracted to the Australian National University as part of its Australian Government funded e-cigarettes evidence review.</span></em></p>Governments and health bodies agree: it’s time for action on vape imports and sale. But which option will they choose?Becky Freeman, Associate Professor, School of Public Health, University of SydneyPaul Grogan, Senior Adviser, The Daffodil Centre, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1979132023-03-20T19:23:21Z2023-03-20T19:23:21ZHow bad is vaping and should it be banned?<figure><img src="https://images.theconversation.com/files/514615/original/file-20230310-18-d4sd7f.jpg?ixlib=rb-1.1.0&rect=0%2C7%2C4928%2C3245&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">nery zarate/unsplash</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Vaping regularly makes headlines, with some campaigning to make e-cigarettes more available to help smokers quit, while others are keen to see vaping products banned, citing dangers, especially for teens.</p>
<p>So just how dangerous is it? We have undertaken an <a href="https://360edge.com.au/assets/uploads/2023/03/360Edge-What-Works-in-Tobacco-Harm-Reduction-and-Vaping-March-2023.pdf">evidence check of vaping research</a>. This included more than 100 sources on tobacco harm reduction, vaping prevalence and health effects, and what other countries are doing in response. Here’s what we found.</p>
<h2>How does vaping compare to smoking?</h2>
<p>Smoking is harmful. It’s the <a href="https://www.aihw.gov.au/reports/burden-of-disease/abds-impact-and-causes-of-illness-and-death-in-aus/summary">leading preventable cause of death</a> in Australia. It causes <a href="https://www.aihw.gov.au/reports/burden-of-disease/abds-impact-and-causes-of-illness-and-death-in-aus/summary">13% of all deaths</a>, <a href="https://elifesciences.org/articles/49979">including from</a> lung, mouth, throat and bladder cancer, emphysema, heart attack and stroke, to name just a few. People who smoke regularly and don’t quit <a href="https://www.nejm.org/doi/pdf/10.1056/NEJMsa1211128">lose about ten years of life</a> compared with non-smokers.</p>
<p>Nicotine, a mild stimulant, is the active ingredient in both cigarettes and nicotine vaping products. It’s addictive but isn’t the cause of cancer or the other diseases related to smoking.</p>
<p>Ideally, people wouldn’t be addicted to nicotine, but having a safe supply without the deadly chemicals, for instance by using nicotine patches or gum, is safer than smoking. Making these other sources available is known as “harm reduction”.</p>
<p>Vaping is not risk-free, but several detailed <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/684963/Evidence_review_of_e-cigarettes_and_heated_tobacco_products_2018.pdf">reviews of the evidence</a> plus a <a href="https://www.karger.com/Article/FullText/360220">consensus of experts</a> have all <a href="https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction">estimated</a> it’s at least <a href="https://www.gov.uk/government/publications/e-cigarettes-and-heated-tobacco-products-evidence-review">95% safer</a> to vape nicotine than to smoke tobacco. The risk of cancer from vaping, for example, has been estimated at less than 1%.</p>
<p>These reviews looked at the known dangerous chemicals in cigarettes, and found there were very few and in very small quantities in nicotine vapes. So the argument that we won’t see major health effects for a few more decades is causing more alarm than is necessary.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/514618/original/file-20230310-14-lxz6u2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Pile of cigarette butts" src="https://images.theconversation.com/files/514618/original/file-20230310-14-lxz6u2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/514618/original/file-20230310-14-lxz6u2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/514618/original/file-20230310-14-lxz6u2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/514618/original/file-20230310-14-lxz6u2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/514618/original/file-20230310-14-lxz6u2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/514618/original/file-20230310-14-lxz6u2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/514618/original/file-20230310-14-lxz6u2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Smoking is the #1 preventable cause of death in Australia.</span>
<span class="attribution"><span class="source">pawel czerwinski/unsplash</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>Is ‘everyone’ vaping these days?</h2>
<p>Some are concerned about the use of vaping products by teens, but currently available statistics show very few teens vape regularly. Depending on the study, between <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/contents/summary">9.6%</a> and <a href="https://www.sydney.edu.au/news-opinion/news/2022/09/27/study-provides-new-insights-on-teen-vaping-behaviour-in-australia.html">32%</a> of 14-17-year-olds have tried vaping at some point in their lives. </p>
<p>But <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/contents/summary">less than 2%</a> of 14-17-year-olds say they have used vapes in the past year. This number doubled between 2016 and 2019, but is still much lower than the rates of teen smoking (3.2%) and teen alcohol use (32%).</p>
<p>It’s the same pattern we see with drugs other than alcohol: a proportion of people try them but only a very small proportion of those go on to use regularly or for a long time. Nearly 60% of people who try vaping <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/contents/summary">only use once or twice</a>.</p>
<p><a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/contents/summary">Smoking rates in Australia</a> have declined from 24% in 1991 to 11% in 2019 because we have introduced a number of very successful measures such as restricting sales and where people can smoke, putting up prices, introducing plain packaging, and improving education and access to treatment programs.</p>
<p>But it’s getting harder to encourage the remaining smokers to quit with the methods that have worked in the past. Those still smoking tend to be <a href="https://www.abs.gov.au/articles/pandemic-insights-australian-smokers-2020-21">older</a>, more <a href="https://www.tobaccoinaustralia.org.au/chapter-9-disadvantage/in-depth">socially disadvantaged</a>, or have <a href="https://www.tobaccoinaustralia.org.au/chapter-9-disadvantage/in-depth">mental health</a> problems.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/my-teens-vaping-what-should-i-say-3-expert-tips-on-how-to-approach-the-talk-196205">My teen's vaping. What should I say? 3 expert tips on how to approach 'the talk'</a>
</strong>
</em>
</p>
<hr>
<h2>Should we ban vapes?</h2>
<p>So we have a bit of a dilemma. Vaping is much safer than smoking, so it would be helpful for adults to have access to it as an alternative to cigarettes. That means we need to make them more available and accessible.</p>
<p>But ideally we don’t want teens who don’t already smoke to start regular vaping. This has led some to call for a “<a href="https://www.9news.com.au/national/vaping-australia-what-are-the-laws-issues-latest-scientific-studies-explainer/82d035d1-a9ce-4485-9e5b-52dcca1ded92">crackdown</a>” on vaping.</p>
<p>But we know from a long history of <a href="https://theconversation.com/history-not-harm-dictates-why-some-drugs-are-legal-and-others-arent-110564">drug prohibition</a> - like alcohol prohibition in the 1920s - that banning or restricting vaping could actually do more harm than good.</p>
<p>Banning drugs doesn’t stop people using them - more than 43% of <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/contents/summary">Australians have tried an illicit drug</a> at least once. And it has very little impact on the availability of drugs. </p>
<p>But prohibition does have a number of unintended consequences, including driving drugs underground and creating a <a href="https://www.abc.net.au/news/2022-04-08/illegal-vape-tobacco-trade-booming-in-queensland/100964858">black market</a> or <a href="https://pubmed.ncbi.nlm.nih.gov/27021149/">increasing harms</a> as people switch to other drugs, which are often more dangerous.</p>
<p>The black market <a href="https://theconversation.com/history-not-harm-dictates-why-some-drugs-are-legal-and-others-arent-110564">makes drugs more dangerous</a> because there is no way to control quality. And it makes it easier, not harder, for teens to access them, because there are no restrictions on who can sell or buy them.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/learning-about-the-health-risks-of-vaping-can-encourage-young-vapers-to-rethink-their-habit-199557">Learning about the health risks of vaping can encourage young vapers to rethink their habit</a>
</strong>
</em>
</p>
<hr>
<h2>Are our current laws working?</h2>
<p>In 2021, Australia made it illegal to possess and use nicotine vaping products without a prescription. We are the only country in the world to take this path.</p>
<p>The problem is even after more than a year of this law, <a href="https://www.cancervic.org.au/downloads/cbrc/R22_MB_E-cigarette%20use%20and%20purchasing%20behaviour%20among%20Victorian%20adults.pdf">only 8.6%</a> of people vaping nicotine have a prescription, meaning more than 90% buy them illegally.</p>
<p><a href="https://www.theguardian.com/australia-news/2022/nov/29/government-to-crack-down-on-nicotine-e-cigarettes-as-rates-of-teen-vaping-skyrocket">Anecdotal reports</a> even suggest an increase in popularity of vaping among teens since these laws were introduced. At best, they are not helping.</p>
<p>It may seem counterintuitive, but the way to reduce the black market is to make quality-controlled vapes and liquids more widely available, but restricted to adults. If people could access vaping products legally they wouldn’t buy them on the black market and the black market would decline.</p>
<p>We also know from many studies on <a href="https://theconversation.com/ex-ice-users-lecturing-school-kids-isnt-the-answer-to-preventing-drug-use-64753">drug education</a> in schools that when kids get accurate, non-sensationalised information about drugs they tend to make healthier decisions. Sensationalised information can have the opposite effect and <a href="https://journals.sagepub.com/doi/10.1177/0017896915612227">increase interest in drugs</a>. So <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/dar.12986">better education in schools</a> and for parents and teachers is also needed, so they know how to talk to kids about vaping and what to do if they know someone is vaping.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/rod4d4yFeaE?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<h2>What have other countries done?</h2>
<p>Other countries allow vapes to be legally sold without a prescription, but impose strict quality controls and do not allow the sale of products to people under a minimum age. This is similar to our regulation of cigarettes and alcohol.</p>
<p>The <a href="https://www.gov.uk/government/publications/nicotine-vaping-in-england-2022-evidence-update/nicotine-vaping-in-england-2022-evidence-update-summary">United Kingdom</a> has minimum standards on manufacturing, as well as restrictions on purchase age and where people can vape.</p>
<p><a href="https://www.theguardian.com/world/2022/dec/13/new-zealand-passes-world-first-tobacco-law-to-ban-smoking-by-2025">Aotearoa New Zealand</a> introduced a unique plan to reduce smoking rates by imposing a lifetime ban on buying cigarettes. Anyone born after January 1 2009 will never be able to buy cigarettes, so the minimum age you can legally smoke keeps increasing. At the same time, NZ <a href="https://vapingfacts.health.nz/the-facts-of-vaping/vaping-law-and-policy/">increased access</a> to vaping products under strict regulations on manufacture, purchase and use.</p>
<p>As of late last year, <a href="https://www.cdc.gov/statesystem/factsheets/ecigarette/ECigarette.html">all US states</a> require sellers to have a retail licence, and sales to people under 21 are banned. There are also restrictions on where people can vape.</p>
<p>A <a href="https://academic.oup.com/ntr/advance-article/doi/10.1093/ntr/ntac210/6693990">recent study</a> modelled the impact of increasing access to nicotine vaping products in Australia. It found it’s likely there would be significant public health benefits by relaxing the current restrictive policies and increasing access to nicotine vaping products for adults.</p>
<p>The question is not whether we should discourage teens from using vaping products or whether we should allow wider accessibility to vaping products for adults as an alternative to smoking. The answer to both those questions is yes.</p>
<p>The key question is how do we do both effectively without one policy jeopardising the outcomes of the other?</p>
<p>If we took a pragmatic harm-reduction approach, as other countries have done, we could use our very successful model of regulation of tobacco products as a template to achieve both outcomes.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/its-safest-to-avoid-e-cigarettes-altogether-unless-vaping-is-helping-you-quit-smoking-123274">It's safest to avoid e-cigarettes altogether – unless vaping is helping you quit smoking</a>
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</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/197913/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Lee works as a consultant in the health sector and a psychologist in private practice. She has previously received funding by Australian and state governments, NHMRC and other bodies for evaluation and research into alcohol and other drug prevention and treatment.</span></em></p><p class="fine-print"><em><span>Brigid Clancy is an Associate at 360Edge, a drug and alcohol consultancy company. </span></em></p>A new review has examined the research on vaping. It found Australia is in need of a pragmatic harm reduction approach.Nicole Lee, Professor at the National Drug Research Institute (Melbourne), Curtin UniversityBrigid Clancy, PhD Candidate (Psychiatry) & Research Assistant, University of NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2007082023-03-05T19:20:17Z2023-03-05T19:20:17ZA potted history of smoking, and how we’re making the same mistakes with vaping<figure><img src="https://images.theconversation.com/files/513309/original/file-20230303-18-tocrry.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> </figcaption></figure><p>When smoking first became popular we were told it was healthy, it was heavily marketed (including to young people) as being cool, and the time it took for us to learn otherwise was long, and came too late for many. Unfortunately, it seems history is repeating itself with vaping.</p>
<p>Before the invention of machines to make cigarettes, they were hand-rolled – with an experienced roller making around 240 cigarettes an hour. When mechanisation arrived in the late nineteenth century, early machines could make 12,000 per hour. Eventually, they could churn out <a href="https://www.pmi.com/investor-relations/overview/how-cigarettes-are-made">1.2 million an hour</a>. </p>
<p>This made smoking immensely affordable, accessible to those on even meagre incomes. These machines would go on to become perhaps the worst development in public health history.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/513320/original/file-20230303-14-mtvyn3.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Advertisement reading 'More doctors smoke camels than any other cigarette'" src="https://images.theconversation.com/files/513320/original/file-20230303-14-mtvyn3.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/513320/original/file-20230303-14-mtvyn3.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=755&fit=crop&dpr=1 600w, https://images.theconversation.com/files/513320/original/file-20230303-14-mtvyn3.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=755&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/513320/original/file-20230303-14-mtvyn3.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=755&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/513320/original/file-20230303-14-mtvyn3.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=949&fit=crop&dpr=1 754w, https://images.theconversation.com/files/513320/original/file-20230303-14-mtvyn3.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=949&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/513320/original/file-20230303-14-mtvyn3.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=949&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption"></span>
<span class="attribution"><a class="source" href="https://tobacco.stanford.edu/cigarettes/doctors-smoking/more-doctors-smoke-camels/">Screenshot Stanford Research into the Impact of Tobacco Advertising</a></span>
</figcaption>
</figure>
<p>Combined with <a href="https://tobaccotactics.org/wiki/advertising-strategy/">mass cigarette advertising</a>, including the infamous 1940s “<a href="https://tobacco.stanford.edu/cigarettes/doctors-smoking/more-doctors-smoke-camels/">More doctors smoke Camel than any other cigarette</a>” which successfully distracted the population from early concerns about harm, cheap cigarettes saw smoking prevalence skyrocket globally. </p>
<p><a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-015-0281-z">Two in three long-term smokers died from their addiction</a>.</p>
<p>Ever since, governments have been struggling to introduce potent controls on Big Tobacco. The World Health Organization’s 2003 <a href="https://fctc.who.int/who-fctc/overview">Framework Convention on Tobacco Control</a> has an entire section devoted to ways of <a href="https://escholarship.org/uc/item/98w687x5">minimising industry interference</a>.</p>
<h2>Lung cancer was rare</h2>
<p>Despite <a href="https://ehne.fr/en/encyclopedia/themes/ecology-and-environment-in-europe/environmental-risks/industrial-pollution-in-europe">heavy industrial air pollution</a> in cities dating from the early 1800s, lung cancer was a rare disease. <a href="https://journal.chestnet.org/article/S0012-3692(15)34009-5/fulltext">US surgeon Alton Ochsner</a>, recalling attendance at his first lung cancer autopsy in 1919, was told he and his fellow interns “might never see another such case as long as we lived”. </p>
<p>He saw no further cases until 1936, and then saw another nine cases in six months. Given the smoking boom that occurred in the US with World War I, Ochsner was quick to assume cigarettes were to blame. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/513303/original/file-20230302-18-j0i1mo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Highlighted spots on a chest x-ray" src="https://images.theconversation.com/files/513303/original/file-20230302-18-j0i1mo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/513303/original/file-20230302-18-j0i1mo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=525&fit=crop&dpr=1 600w, https://images.theconversation.com/files/513303/original/file-20230302-18-j0i1mo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=525&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/513303/original/file-20230302-18-j0i1mo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=525&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/513303/original/file-20230302-18-j0i1mo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=660&fit=crop&dpr=1 754w, https://images.theconversation.com/files/513303/original/file-20230302-18-j0i1mo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=660&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/513303/original/file-20230302-18-j0i1mo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=660&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Before smoking took off in the early 20th century, lung cancer was a rarity.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Since the 1960s, lung cancer has been (by far) the world’s <a href="https://acsjournals.onlinelibrary.wiley.com/doi/10.3322/caac.21660">leading cause of cancer death</a>. Lung cancer (<a href="https://www.cdc.gov/cancer/lung/basic_info/risk_factors.htm#:%7E:text=Cigarette%20smoking%20is%20the%20number,of%20more%20than%207%2C000%20chemicals.">almost all</a> of which can be attributed to smoking) was responsible for 18% of all cancer deaths in 2020, with the next most frequent killer, liver cancer, at 8.3%.</p>
<p>Most public health graduates in recent decades are familiar with a <a href="https://tobaccocontrol.bmj.com/content/tobaccocontrol/3/3/242.full.pdf">famous 1994 graph</a> illustrating the shape of the tobacco-caused disease epidemic across time. The graph shows four stages of the smoking and disease epidemics. </p>
<p>Nations in the first 20 year-long stage have accelerating smoking but negligible tobacco-caused disease. By the fourth stage, smoking is declining but disease is growing more rapidly than ever. These gaps are known as <a href="https://www.youtube.com/watch?v=bhTJaESyFOA">latency periods</a> in epidemiology.</p>
<p>Mesothelioma caused by breathing asbestos fibres also follows this pattern. The latency period between initial exposure and the onset of symptoms can be <a href="https://www.mesothelioma.com/mesothelioma/latency-period/#:%7E:text=Mesothelioma%20latency%20period%20is%20the,and%20the%20duration%20of%20exposure.">up to 50 years</a>.</p>
<hr>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/513311/original/file-20230303-20-de2cgx.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/513311/original/file-20230303-20-de2cgx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/513311/original/file-20230303-20-de2cgx.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=576&fit=crop&dpr=1 600w, https://images.theconversation.com/files/513311/original/file-20230303-20-de2cgx.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=576&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/513311/original/file-20230303-20-de2cgx.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=576&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/513311/original/file-20230303-20-de2cgx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=724&fit=crop&dpr=1 754w, https://images.theconversation.com/files/513311/original/file-20230303-20-de2cgx.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=724&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/513311/original/file-20230303-20-de2cgx.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=724&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://tobaccocontrol.bmj.com/content/tobaccocontrol/3/3/242.full.pdf">Source: Tobacco Control 1994</a></span>
</figcaption>
</figure>
<hr>
<h2>Enter nicotine vaping products</h2>
<p>Vaping has only been widespread for about ten years. So, if it causes serious diseases such as lung cancer, cardiovascular or respiratory disease, we would expect very few cases by now. This has not stopped <a href="https://ajph.aphapublications.org/doi/10.2105/AJPH.2019.305424">cavalier</a> declarations that vaping is “95% less dangerous than smoking”.</p>
<p>This statistic is still used by many, despite the paper that gave birth to this factoid <a href="https://www.karger.com/Article/FullText/360220">admitting</a> there is a lack of evidence for most of the criteria used to assess vaping’s harms. </p>
<p>There is a great deal of early evidence now available that vaping is likely to be anything but benign. For example, recent reviews on vapes have found they <a href="https://pubmed.ncbi.nlm.nih.gov/33429159/">contain carcinogens known to cause lung cancer</a>, <a href="https://www.tandfonline.com/doi/abs/10.1080/02770903.2021.1971703?journalCode=ijas20">are correlated with asthma</a>, and <a href="https://www.frontiersin.org/articles/10.3389/fphys.2020.00492/full">impair our vascular systems</a>.</p>
<p>Knowledge about the deadly toxicology of tobacco smoke emerged over decades. By contrast, the many thousands of flavouring chemicals in vapes present bewildering challenges for regulators.</p>
<p>In 2021, the US Flavour and Extracts Manufacturing Association <a href="https://web.archive.org/web/20211015203320/https://www.femaflavor.org/node/24344">declared</a> “E-cigarette manufacturers should not represent or suggest that the flavor ingredients used in their products are safe […] because such statements are false and misleading”. Regulators have never allowed asthma drug inhalers to contain flavourants.</p>
<p>All forms of tobacco advertising and promotion have long been <a href="https://tobaccocontrol.bmj.com/content/tobaccocontrol/31/2/216.full.pdf">banned or seriously restricted in many nations</a>. But vaping emerged in the internet era where regulation presents formidable barriers. Social media today are awash with vaping promotions, with illegal vapes flagrantly being sold as “fruit” on Facebook Marketplace.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/513300/original/file-20230302-20-4w08bk.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Screenshot of vaping ads." src="https://images.theconversation.com/files/513300/original/file-20230302-20-4w08bk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/513300/original/file-20230302-20-4w08bk.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=548&fit=crop&dpr=1 600w, https://images.theconversation.com/files/513300/original/file-20230302-20-4w08bk.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=548&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/513300/original/file-20230302-20-4w08bk.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=548&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/513300/original/file-20230302-20-4w08bk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=688&fit=crop&dpr=1 754w, https://images.theconversation.com/files/513300/original/file-20230302-20-4w08bk.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=688&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/513300/original/file-20230302-20-4w08bk.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=688&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Advertisements for ‘fruit’ on Facebook are really for vapes.</span>
<span class="attribution"><span class="source">Author Screenshot.</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Research has shown indoor areas with many vapers contain <a href="https://tobaccocontrol.bmj.com/content/tobaccocontrol/26/1/109.full.pdf">airborne particulate matter concentrations</a> higher than crowded bars in the days when smoking was permitted. <a href="https://www.misteliquid.co.uk/blog/travelling-with-an-ecig/#:%7E:text=All%20airlines%20have%20banned%20the,packed%20in%20your%20hand%20luggage">No airline in the world</a> permits in-flight vaping.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/passive-vaping-time-we-see-it-like-secondhand-smoke-and-stand-up-for-the-right-to-clean-air-198766">Passive vaping – time we see it like secondhand smoke and stand up for the right to clean air</a>
</strong>
</em>
</p>
<hr>
<h2>Repeating the same mistakes</h2>
<p>With children’s vaping accelerating dramatically in <a href="https://insightplus.mja.com.au/2023/1/vaping-and-e-cigarette-use-on-the-rise-among-young-people/">Australia</a>, <a href="https://www150.statcan.gc.ca/n1/daily-quotidien/220720/dq220720d-eng.htm">Canada</a>, the <a href="https://newsinhealth.nih.gov/2019/02/vaping-rises-among-teens">US</a>, <a href="https://www.theguardian.com/society/2022/jul/23/child-vaping-epidemic-risks-becoming-public-health-catastrophe-in-uk-experts-warn">United Kingdom</a> and <a href="https://theconversation.com/young-non-smokers-in-nz-are-taking-up-vaping-more-than-ever-before-here-are-5-reasons-why-185400">New Zealand</a>, governments are scrambling to find solutions to the problem they created by rash, rushed policies.</p>
<p>Vaping advocates argue laws and regulations for vapes should be no more harsh than those that apply to cigarettes. So with no restrictions on where cigarettes can be sold, we see <a href="https://www.theguardian.com/australia-news/2023/feb/26/facebook-ads-opposing-a-ban-on-vaping-in-australia-failed-to-disclose-tobacco-company-backing">tobacco industry-led efforts today</a> in Australia trying to allow vapes to be sold under the same conditions.</p>
<p>The first baby steps in Australian tobacco control were <a href="https://tobaccocontrol.bmj.com/content/tobaccocontrol/12/suppl_3/iii13.full.pdf">tiny health warnings</a> that appeared in 1973. It then took 40 years to fight for all the policies and quit campaign funding that have together taken smoking down to its <a href="https://www.abs.gov.au/statistics/health/health-conditions-and-risks/smoking/latest-release">lowest ever levels</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/513305/original/file-20230302-16-elpdil.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Cigarette packets showing an eyeball and the warning 'smoking causes blindness'" src="https://images.theconversation.com/files/513305/original/file-20230302-16-elpdil.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/513305/original/file-20230302-16-elpdil.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=367&fit=crop&dpr=1 600w, https://images.theconversation.com/files/513305/original/file-20230302-16-elpdil.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=367&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/513305/original/file-20230302-16-elpdil.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=367&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/513305/original/file-20230302-16-elpdil.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=461&fit=crop&dpr=1 754w, https://images.theconversation.com/files/513305/original/file-20230302-16-elpdil.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=461&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/513305/original/file-20230302-16-elpdil.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=461&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Graphic health warnings now dominate cigarette packets free of branding. But it took 40 years to get here.</span>
<span class="attribution"><a class="source" href="https://www.accc.gov.au/system/files/Tobacco%20graphic%20health%20warnings%20-%20fact%20card_0.pdf">ACCC Product Safety Supplier Guide</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>This 40 years was due to both early ignorance of the latent size of the emerging smoking disease epidemic, and sustained pressure from the tobacco industry to defeat, delay and dilute every policy that threatened to reduce smoking.</p>
<p>Just as the tobacco industry for decades denied targeting children, we are seeing <a href="https://www.nbcnews.com/health/kids-health/e-cigarette-ads-target-millions-kids-cdc-says-n490601">almost identical claims and strategies</a> being used by vaping industries today. And it’s important to note all major tobacco companies are now also manufacturing vapes, so it’s not just the same game, it’s the same players.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/marketers-are-targeting-teens-with-cheap-and-addictive-vapes-9-ways-to-stem-rising-rates-of-youth-vaping-198291">Marketers are targeting teens with cheap and addictive vapes: 9 ways to stem rising rates of youth vaping</a>
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<p>It’s often said that if cigarettes were invented tomorrow, and we knew now what we didn’t know then, no government in the world would permit their sale (let alone allow them to be sold in every convenience store). But this is what is happening now with vapes.</p>
<p>With pharmaceutical products that save lives, treat illness and reduce severe pain, we allow only people with a four-year pharmacy degree to sell them, and only to those with a temporary licence (a dose- and time-limited prescription) issued by a doctor. With cigarettes, we foolishly allowed them to be sold everywhere.</p>
<p>All health departments in Australia, most major political parties, nearly every health and medical agency in Australia and <a href="https://simonchapman6.com/2019/05/20/global-regional-and-national-agencies-concerned-about-e-cigarettes-statements-you-are-unlikely-to-hear-from-vaping-advocates/">many internationally, including the WHO</a>, are saying vapes should be strongly regulated.</p>
<p>Vaping advocates argue we need vapes to help smokers quit, but the evidence they do that is <a href="https://simonchapman6.com/vaping-research-alerts/#smoking-cessation">weak</a>.</p>
<p>Currently vaping devices are widely available, but those including vaping liquids containing nicotine are only legally available with a prescription in Australia. This doesn’t stop people buying them easily online or from many convenience stores blatantly breaking the law. </p>
<p>The previous health minister tried to ban personal importation of nicotine vapes and liquid, and the current one expressed interest in doing the same before a period of public consultation <a href="https://www.tga.gov.au/resources/consultation/consultation-proposed-reforms-regulation-nicotine-vaping-products">via the Therapeutic Goods Administration</a>. </p>
<p>As with Australia pioneering plain packaging laws in 2012, if the import ban is implemented we will again quickly be emulated by other nations. And again detested by the tobacco giants.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/learning-about-the-health-risks-of-vaping-can-encourage-young-vapers-to-rethink-their-habit-199557">Learning about the health risks of vaping can encourage young vapers to rethink their habit</a>
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<img src="https://counter.theconversation.com/content/200708/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Chapman in the past has receive funding from the National Health and Medical Research Council and the US National Institutes of Health. </span></em></p>It’s often said if cigarettes were invented tomorrow, and we knew now what we didn’t know then, they would be banned outright. But vaping is showing us we’re repeating the same mistakes.Simon Chapman, Emeritus Professor in Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1957102022-12-01T06:34:23Z2022-12-01T06:34:23ZBanning menthol cigarettes and more health warnings are only the start. Australia could look to NZ for how to do tobacco control<figure><img src="https://images.theconversation.com/files/498360/original/file-20221130-12-akaqcq.jpg?ixlib=rb-1.1.0&rect=2%2C0%2C1914%2C1279&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/7USMFYqt1NI">Pawel Czerwinski/Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>This week’s <a href="https://www.abc.net.au/news/2022-11-30/government-to-ban-menthol-cigarettes-ugly-colours/101715174">announcement</a> of a raft of new tobacco control measures – including banning menthol products and proposing health warnings on individual cigarettes – are important and welcome.</p>
<p>We applaud Australian Health Minister Mark Butler’s <a href="https://www.croakey.org/wp-content/uploads/2022/12/ButlerSpeechTobacco.pdf">aim</a> to re-establish Australia as a global leader in tobacco control alongside fellow OECD nations, such as New Zealand and Canada.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1597832911327305729"}"></div></p>
<p>His announcement comes <a href="https://theconversation.com/australias-decisive-win-on-plain-packaging-paves-way-for-other-countries-to-follow-suit-140553">a decade after</a> Australia implemented world-leading laws that required all tobacco products to be sold in plain packs.</p>
<p>But there is still scope for more comprehensive action to reduce the burden smoking imposes on Australia and particularly on Australia’s Indigenous peoples.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-can-cut-indigenous-smoking-and-save-lives-heres-how-42119">We can cut Indigenous smoking and save lives – here's how</a>
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</em>
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<hr>
<h2>We can look to New Zealand</h2>
<p>Aotearoa-New Zealand offers a useful comparison. The NZ parliament aims to pass legislation in mid-December that takes a different approach to the measures Butler outlined this week. </p>
<p>The <a href="https://www.health.govt.nz/our-work/preventative-health-wellness/tobacco-control/smokefree-aotearoa-2025-action-plan">Aotearoa package</a> of measures were developed in close consultation with Māori leaders. These include making cigarettes non-addictive, greatly reducing the number of tobacco retailers, and creating a smoke-free generation. </p>
<p>These policies focus on fundamental drivers of smoking. The measures will also affect everyone in the same way, thus have great potential to reduce pervasive inequities in smoking rates.</p>
<p>Let’s see how Australia’s plans compare with policy reforms under way in New Zealand and Canada.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/forget-tobacco-industry-arguments-about-choice-heres-what-young-people-think-about-nzs-smokefree-generation-policy-193529">Forget tobacco industry arguments about choice. Here's what young people think about NZ's smokefree generation policy</a>
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<h2>New health warnings</h2>
<p>Graphic images on packets of cigarettes were introduced in Australia <a href="https://www.health.gov.au/sites/default/files/evaluation-of-effectiveness-of-graphic-health-warnings-on-tobacco-product-packaging.pdf">16 years ago</a>, and these warnings have encouraged quitting. But they have lost their initial impact. </p>
<p>New and more varied warnings <a href="https://tobaccocontrol.bmj.com/content/28/e1/e71">will refresh</a> this existing policy as will introducing pack inserts providing “how to quit” information, which have been used in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4542677/">Canada since 2012</a>. </p>
<p>In 2023, Canada is set to become the first country to require health warnings to be printed directly on the <a href="https://blogs.bmj.com/tc/2022/07/08/canada-publishes-proposed-regulations-to-require-a-health-warning-directly-on-every-cigarette/">cigarette stick</a>.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1535877502182236163"}"></div></p>
<p>Butler proposes adopting this measure for Australia, but with the addition of making the cigarette paper an <a href="https://tobaccocontrol.bmj.com/content/25/6/699.long">unattractive colour</a>, such as slimy green or faecal yellow-brown. </p>
<p>Like plain packaging, this measure will reduce the appeal of smoking and present smoking as unambiguously harmful and unattractive.</p>
<h2>Tightening up marketing</h2>
<p>Standardising pack size, filters, and banning terms such as “light” and “organic” in brand names will further limit misleading tobacco marketing.</p>
<p>Likewise, measures that eliminate gimmicks – such as flavoured “<a href="https://tobaccocontrol.bmj.com/content/25/3/275">crushballs</a>” inserted in filters that release a burst of flavour when crushed, or packs that include “bonus” cigarettes to offer a better deal – will further limit how tobacco companies promote their products.</p>
<p>Banning some flavouring additives, <a href="https://theconversation.com/the-us-fda-has-moved-to-ban-menthol-cigarettes-australia-should-do-that-and-more-182435">particularly menthol</a>, will reduce the appeal of smoking for some consumers. </p>
<p>When Canada banned menthol cigarettes federally in 2017, this measure <a href="https://tobaccocontrol.bmj.com/content/early/2022/04/27/tobaccocontrol-2021-057227.long">increased quitting</a> among people who smoked menthol cigarettes.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-us-fda-has-moved-to-ban-menthol-cigarettes-australia-should-do-that-and-more-182435">The US FDA has moved to ban menthol cigarettes. Australia should do that and more</a>
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</em>
</p>
<hr>
<h2>More transparency</h2>
<p>Tobacco companies will need to disclose tobacco sales volumes and pricing, as required in <a href="https://www.health.govt.nz/our-work/preventative-health-wellness/tobacco-control/tobacco-returns">Aotearoa-New Zealand</a>. </p>
<p>Companies will also need to disclose their advertising, promotion and sponsorship activities, as well as product ingredients and emissions. </p>
<p>These moves all reveal important <a href="https://tobaccocontrol.bmj.com/content/early/2022/08/25/tc-2021-057232.info">tobacco company activities</a> that undermine public health efforts. </p>
<p>They will also provide key information about what is in tobacco products, as required by the World Health Organization’s <a href="https://untobaccocontrol.org/impldb/article-10/">Framework Convention on Tobacco Control</a>.</p>
<h2>Vaping ads to be banned</h2>
<p>The final measure will apply tobacco advertising bans to vaping products. This policy will reduce inappropriate promotion of these products, including to young people. </p>
<p>This measure is in addition to, and separate from, the <a href="https://www.tga.gov.au/news/media-releases/tga-consults-potential-nicotine-vaping-product-regulatory-reforms">current review</a> of Australia’s regulation of nicotine vaping products. Addressing the rising problem of vaping among <a href="https://theconversation.com/we-asked-over-700-teens-where-they-bought-their-vapes-heres-what-they-said-190669">young people</a> is a key concern and efforts to reduce youth use are urgently needed.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-asked-over-700-teens-where-they-bought-their-vapes-heres-what-they-said-190669">We asked over 700 teens where they bought their vapes. Here's what they said</a>
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</p>
<hr>
<h2>There’s more to do</h2>
<p>These advances in Australian tobacco control policy align with measures implemented a decade ago in Canada or that are soon to start. We welcome such measures that make smoking less appealing and encourage quitting. </p>
<p>However, bigger jumps are required if Australia is to lead on eradicating the harms smoking causes. These initial measures announced also do not have a clear equity focus, such as the measures being implemented in Aotearoa-New Zealand. These have a bolder ambition of rapidly reducing smoking among both Māori and non-Māori peoples to less than <a href="https://www.smokefree.org.nz/smokefree-in-action/smokefree-aotearoa-2025">5% by 2025</a>.</p>
<p>Aotearoa-New Zealand’s proposed law will fundamentally change tobacco products by reducing the nicotine content to <a href="https://doi.org/10.1016/j.drugpo.2021.103436">non-addictive levels</a>. The law also dramatically reduces tobacco availability by decreasing the number of tobacco retailers by at least 90%, and will make it illegal to sell tobacco to anyone born after December 31 2008. </p>
<p><a href="https://theconversation.com/new-zealands-tobacco-endgame-law-will-be-a-world-first-for-health-heres-what-the-modelling-shows-us-187075">Modelling</a> indicates that Aotearoa-New Zealand’s package of measures are likely to achieve their goal of rapidly phasing out tobacco smoking.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/new-zealands-tobacco-endgame-law-will-be-a-world-first-for-health-heres-what-the-modelling-shows-us-187075">New Zealand’s ‘tobacco endgame’ law will be a world first for health – here’s what the modelling shows us</a>
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<p>These measures go far beyond those Butler proposes for Australia. In particular, removing the product’s addictiveness and reducing availability means casual experimentation among young people will not lead to addiction, and quitting will become much easier for people who currently smoke.</p>
<p>The package of measures announced this week will continue declines in smoking following the “tried and tested” strategy of incrementally ratcheting up restrictions on tobacco products. </p>
<p>In contrast, the Aotearoa approach is a “Tobacco Moonshot” that aims to finish the job of ending the tobacco smoking epidemic in Aotearoa-New Zealand.</p>
<hr>
<p><em>The authors would like to acknowledge Tony Blakely, University of Melbourne, and Andrew Waa, University of Otago, for helpful comments and suggestions.</em></p><img src="https://counter.theconversation.com/content/195710/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Coral Gartner receives funding from National Health and Medical Research Council and Australian Research Council. She is an editor for Tobacco Control, A BMJ journal.</span></em></p><p class="fine-print"><em><span>Janet Hoek receives funding from the Health Research Council of New Zealand and the NZ Cancer Society. She has also received funding from the Royal Society Marsden Fund. She is a member of the Health Coalition Aotearoa's Smokefree Expert Advisory Group and sits on several other advisory groups whose work supports the NZ Aotearoa Government's goal of realising a smokefree nation by 2025. </span></em></p><p class="fine-print"><em><span>Richard Edwards receives funding from the Health Research Council of New Zealand, the NZ Cancer Society, and from the National Institute of Health (USA). He has also received funding from the Royal Society Marsden Fund. He is a member of the Health Coalition Aotearoa's Smokefree Expert Advisory Group and sits on several other advisory groups whose work supports the NZ Aotearoa Government's goal of realising a smokefree nation by 2025.</span></em></p>Australia’s approach is welcome but doesn’t go far enough. New Zealand’s plans are much bolder. Here’s how they compare.Coral Gartner, Director, NHMRC Centre of Research Excellence on Achieving the Tobacco Endgame, The University of QueenslandJanet Hoek, Professor of Public Health, University of OtagoRichard Edwards, Professor of Public Health, University of OtagoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1921982022-10-12T10:06:31Z2022-10-12T10:06:31ZFrom e-cigarettes to hookah pipes, South Africa aims to tighten tobacco laws<figure><img src="https://images.theconversation.com/files/489026/original/file-20221010-22-5b5ku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"> It's estimated that tobacco use kills half of it's consumers.</span> <span class="attribution"><span class="source">Alexander Joe/AFP via Getty Images</span></span></figcaption></figure><p><em>Tobacco is a <a href="https://www.afro.who.int/health-topics/tobacco-control">leading cause of disease</a>. It is estimated that it kills half of its consumers. Over a million additional deaths result from exposure to second hand smoke. Countries around the world are moving towards stricter regulation of tobacco products in compliance with their obligation to the World Health Organisation’s (WHO) <a href="https://fctc.who.int/who-fctc/overview">Framework Convention on Tobacco Control</a>. In <a href="https://www.afro.who.int/news/who-supports-south-africas-draft-bill-control-tobacco-products-and-electronic-delivery-systems">2018</a> South Africa published a tobacco control bill that sought to better regulate the sale of cigarettes and other tobacco products. It’s been revised as the <a href="https://www.youtube.com/watch?v=mXjRz9f2lts">Tobacco Products and Electronic Delivery Systems Control Bill 2021</a> and has been approved for submission to parliament. Ina Skosana speaks to Catherine Egbe, a lead researcher on <a href="https://www.samrc.ac.za/sites/default/files/attachments/2022-05-31/GATSFactsheet.pdf">South Africa’s Global Adult Smoking Survey</a>, about the latest developments.</em></p>
<hr>
<h2>Why has it taken so long to bring the bill before parliament?</h2>
<p>The bill was first released for public comments <a href="https://theconversation.com/how-south-africa-is-tightening-its-tobacco-rules-97382">in 2018</a>. After reviewing all the comments, the Department of Health had to do more consultations and update the 2018 version.</p>
<p>Under normal circumstances the process would not take this long. Introducing a law that is focused on protecting people’s health, and impacts on the big industries that make money off the products, will always be a challenge, no matter how harmful the products are.</p>
<p>Bills that have a wider impact on society usually take longer to pass because the consultation process takes time, but a delay of four years is not ideal. </p>
<p>We are happy that the bill is back on track. </p>
<h2>What are the major changes to the 2018 version of the bill?</h2>
<p>The first improvement is that it takes care of novel products – these now go beyond just e-cigarettes to include oral nicotine pouches, and other novel products related to tobacco or nicotine. It also includes future innovations that the industry may come up with.</p>
<p>The tobacco control landscape is very dynamic in terms of product types. One of the key problems we’re having today in South Africa is that the existing law doesn’t regulate electronic cigarettes or other novel products. </p>
<p>So you need a law that takes into account that there could be changes even tomorrow. The current bill, therefore, takes care of future innovations so that such products can fall within the tobacco regulatory framework in South Africa.</p>
<h2>What are the chances of this bill being passed?</h2>
<p>The administrative and political leadership of the Department of Health is committed to, and passionate about protecting South Africans from tobacco related harms. But it’s not in their hands anymore. They’ve done their part. It’s now left to the members of parliament and the public to make this bill become law. This is where citizens’ action will make impact. They must put pressure on parliament to pass this bill. The health of the nation should take precedence over profit from tobacco. </p>
<h2>Why is it important to update restrictions on tobacco use?</h2>
<p>South Africa introduced the very first <a href="https://www.gov.za/documents/tobacco-products-control-act#:%7E:text=The%20Tobacco%20Products%20Control%20Act,provide%20for%20matters%20connected%20therewith">Tobacco Control Act</a> in the 1990s. That law has been updated three times – in 1999, 2007, 2008. </p>
<p>The initial law came into place way before the WHO treaty and before many of these novel products were available. As a signatory to the WHO tobacco control framework, South Africa must make its laws align with the WHO treaty. </p>
<p>In the 1990s the country was a regional leader in tobacco control. It had some of the most stringent tobacco control laws. But the tobacco industry has since come up with new products and ways around the restrictions. South Africa has now fallen behind the rest of the world. As a result, South Africa has regressed and smoking prevalence has steadily increased over the past couple of years.</p>
<p>When the country first introduced tobacco control legislation, it had a smoking prevalence of over <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758983/pdf/v001p00272.pdf">30%</a>. This subsequently fell to as low as 16% in 2010. But is has began to increase.</p>
<p>We’ve been monitoring the trends of tobacco use. One of the surveys I have been using is the <a href="https://hsrc.ac.za/special-projects/sasas/">South African Social Attitudes Survey</a>. </p>
<p>The global adult tobacco survey, which we conducted <a href="https://www.samrc.ac.za/sites/default/files/attachments/2022-05-31/GATSFactsheet.pdf">last year</a>, shows that 29.4% of South Africans use various tobacco products. And 25.8% smoke tobacco. This is proof that the current law is obsolete. It’s not doing what it’s supposed to do – which is to drive down the tobacco use prevalence. </p>
<h2>What are the main drivers of increase in smoking prevalence?</h2>
<p>The industry is using many tactics to get young people to start smoking. In the global adult tobacco survey, we found that the average age of initiation of smoking in South Africa was 17.6 years. About 74% of current smokers started when they were teenagers. So what does the industry do? It employs what I call the “catch them young” approach. It tries to target these young people to get them hooked on nicotine.</p>
<p>Nicotine is one of the most <a href="https://www.fda.gov/tobacco-products/health-effects-tobacco-use/nicotine-why-tobacco-products-are-addictive">addictive</a> drugs. Once hooked, the smoker keeps looking for the product. That’s why the industry targets young people by using celebrities on social media, and new products that contain exotic flavours. Exotic flavours <a href="https://tobaccocontrol.bmj.com/content/25/Suppl_2/ii32">appeal more</a> to children than adults. </p>
<p>Then electronic cigarettes came on board. Nicotine is one of the common components between electronic cigarettes and traditional tobacco products. </p>
<p><a href="https://tobacco.ucsf.edu/convincing-analysis-e-cigs-are-gateway-cigarette-smoking-studies-around-world">Studies </a> from around the world show that some people who may not have smoked, ended up smoking traditional products after starting with electronic cigarettes.</p>
<h2>What are the risks of not regulating tobacco products?</h2>
<p>Any delay in controlling tobacco will cause a lot of deaths from tobacco related diseases. Tobacco is one of the leading causes of noncommunicable diseases. These conditions are the leading cause of death in South Africa and in many parts of the world. If the legislation is delayed further, more young people are at risk of getting hooked on nicotine, with dire consequences.</p>
<p>In 2016, the healthcare <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7822111/">cost</a> of tobacco use was R14.48 billion in South Africa. The tobacco industry only <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7822111/">contributed</a> about R12 billion in taxes. So at the end of the day, who is benefiting more from tobacco?</p><img src="https://counter.theconversation.com/content/192198/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine O. Egbe, PhD has received research grant from the Campaign For Tobacco-Free Kids. </span></em></p>South Africa was once a leader in tobacco use control but has since fallen behind, and smoking prevalence has steadily increased.Catherine O. Egbe, PhD, Specialist Scientist, Alcohol Tobacco and Other Drug Research Unit, South African Medical Research CouncilLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1906692022-09-26T20:02:29Z2022-09-26T20:02:29ZWe asked over 700 teens where they bought their vapes. Here’s what they said<figure><img src="https://images.theconversation.com/files/486212/original/file-20220923-49066-sikp9n.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1917%2C1276&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/a-man-young-man-sitting-on-a-chair-with-a-vape-on-hand-10951435/">Mushtaq Hussain/Pexels</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Teen vaping has been in the news, with reports of <a href="https://www.smh.com.au/national/nsw/number-of-young-people-vaping-doubles-in-a-year-as-smoking-rates-drop-20220531-p5apur.html">rapidly increasing use</a> and <a href="https://www.smh.com.au/world/asia/from-bootcamps-in-china-to-australian-schools-how-vapes-hook-children-on-nicotine-20210830-p58n6w.html">illegal sales</a> of e-cigarettes.</p>
<p>As a Four Corners <a href="https://www.abc.net.au/4corners/vape-haze:-the-new-addiction-of-vaping/13948226">documentary</a> on ABC TV earlier this year showed, parents and schools are struggling to manage this swift rise in vaping, with fears children are addicted and harming their health.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1539762788876181505"}"></div></p>
<p>In contrast, very limited research about Australian teen vaping has been published, until today.</p>
<p>We have <a href="https://onlinelibrary.wiley.com/doi/10.1111/1753-6405.13316">published</a> in the Australian and New Zealand Journal of Public Health the first results from the <a href="https://www.cancercouncil.com.au/cancer-prevention/smoking/electronic-cigarettes/generation-vape/">Generation Vape</a> study. The study aims to to track teenagers’ knowledge, attitudes, beliefs and behaviours about using vapes (e-cigarettes). </p>
<p>Here’s what we found about where teenagers were accessing vapes and what types of products they use.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/a-damning-review-of-e-cigarettes-shows-vaping-leads-to-smoking-the-opposite-of-what-supporters-claim-180675">A damning review of e-cigarettes shows vaping leads to smoking, the opposite of what supporters claim</a>
</strong>
</em>
</p>
<hr>
<h2>Vaping common, especially in non-smokers</h2>
<p>We surveyed more than 700 teenagers 14-17 years old from New South Wales. The sample was closely representative of the population, with key characteristics such as age, gender, location and education monitored throughout data collection.</p>
<p>We found teenagers are readily accessing and using illegal, flavoured, disposable vaping products that contain nicotine. </p>
<p>Among the teens surveyed, 32% had ever vaped, at least a few puffs. Of these, more than half (54%) had never previously smoked.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/a-parents-guide-to-why-teens-make-bad-decisions-88246">A parent's guide to why teens make bad decisions</a>
</strong>
</em>
</p>
<hr>
<h2>Where are teens getting vapes from?</h2>
<p>We found most teens (70%) didn’t directly buy the last vape they used. The vast majority (80%) of these got it from their friends. </p>
<p>However, for the 30% who did buy their own vape, close to half (49%) bought it from a friend or another individual, and 31% bought it from a retailer such as a petrol station, tobacconist or convenience store.</p>
<p>Teens also said they bought vapes through social media, at vape stores and via websites.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-can-we-reverse-the-vaping-crisis-among-young-australians-enforce-the-rules-185867">How can we reverse the vaping crisis among young Australians? Enforce the rules</a>
</strong>
</em>
</p>
<hr>
<h2>What products are teens using, and why?</h2>
<p>Of the teens who had ever vaped and reported the type of device they used, 86% had used a disposable vape. This confirms anecdotal reports.</p>
<p>These devices appeal to young people and are easy to use. They do not require refilling (unlike tank-style vaping products) and are activated by inhaling on the mouthpiece. </p>
<p>Disposable vapes can contain hundreds, or even thousands of puffs, and are inexpensive, with illicit vapes from retail stores costing between <a href="https://www.smh.com.au/world/asia/from-bootcamps-in-china-to-australian-schools-how-vapes-hook-children-on-nicotine-20210830-p58n6w.html">$20-$30, or as little as $5 online</a>.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/485511/original/file-20220920-3640-p8l88p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/485511/original/file-20220920-3640-p8l88p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=968&fit=crop&dpr=1 600w, https://images.theconversation.com/files/485511/original/file-20220920-3640-p8l88p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=968&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/485511/original/file-20220920-3640-p8l88p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=968&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/485511/original/file-20220920-3640-p8l88p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1217&fit=crop&dpr=1 754w, https://images.theconversation.com/files/485511/original/file-20220920-3640-p8l88p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1217&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/485511/original/file-20220920-3640-p8l88p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1217&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">This ‘Juicy Fruity’ disposable vape resembles Juicy Fruit chewing gum.</span>
<span class="attribution"><span class="source">Author provided</span></span>
</figcaption>
</figure>
<p>There is an enormous range of vape flavours likely to appeal to children – from chewing gum to fruit and soft drink, even desserts. So it is unsurprising teens rated “flavourings and taste” as the most important characteristic of vapes they used.</p>
<p>Disposable vapes often contain very <a href="https://www.health.nsw.gov.au/tobacco/Pages/vaping-evidence-summary.aspx#nicotine">high concentrations of nicotine</a>, even those claiming to be nicotine-free. The way these products <a href="https://www.cdc.gov/tobacco/basic_information/e-cigarettes/pdfs/ecigarette-or-vaping-products-visual-dictionary-508.pdf">are made</a> (using nicotine salts rather than the free-base nicotine you’d find in cigarettes) allows manufacturers to increase the nicotine concentration without causing throat irritation. </p>
<p>In our study, over half (53%) of the teens who had ever vaped said they had used a vape containing nicotine. Many, however, were unsure whether they had used a vape containing nicotine (27%). </p>
<p>All vaping products, irrespective of nicotine content, <a href="https://www.health.gov.au/health-topics/smoking-and-tobacco/about-smoking-and-tobacco/smoking-and-tobacco-laws-in-australia#ecigarette-laws">are illegal</a> to sell to under 18s in Australia.</p>
<p>Today, disposable vapes containing nicotine can only be legally sold in Australia by pharmacies to adult users with a valid prescription.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/many-e-cigarette-vaping-liquids-contain-toxic-chemicals-new-australian-research-169615">Many e-cigarette vaping liquids contain toxic chemicals: new Australian research</a>
</strong>
</em>
</p>
<hr>
<h2>We need to end illegal imports and sales</h2>
<p>Our results emphasise that teen vaping is increasingly normalised, and the most popular devices are designed to be highly appealing to young people. This is despite product manufacturers and proponents claiming they are <a href="https://theconversation.com/twelve-myths-about-e-cigarettes-that-failed-to-impress-the-tga-72408">smoking cessation aids</a> only for adult smokers who are struggling to quit. </p>
<p>Turning the tide on teen vaping requires strong and immediate policy action, including ending the illicit importation and sale of vaping products.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/486211/original/file-20220923-23143-107ras.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Hand reach for vape and vape products on store shelf" src="https://images.theconversation.com/files/486211/original/file-20220923-23143-107ras.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/486211/original/file-20220923-23143-107ras.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=480&fit=crop&dpr=1 600w, https://images.theconversation.com/files/486211/original/file-20220923-23143-107ras.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=480&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/486211/original/file-20220923-23143-107ras.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=480&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/486211/original/file-20220923-23143-107ras.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=603&fit=crop&dpr=1 754w, https://images.theconversation.com/files/486211/original/file-20220923-23143-107ras.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=603&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/486211/original/file-20220923-23143-107ras.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=603&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">We need to clamp down on the illegal sale of e-cigarettes.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/8RN9UZeL-fo">E-Liquids UK/Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p><a href="https://www.health.nsw.gov.au/vaping">Education</a> is often the default first action to address unhealthy behaviours in young people. However, unless this is coupled with strong, supportive policy action, this approach is unlikely to have any measurable impact. Education campaigns cannot protect young people from an industry that so freely disregards laws meant to protect health.</p>
<p>We have <a href="https://openresearch-repository.anu.edu.au/bitstream/1885/262914/1/Electronic%20cigarettes%20health%20outcomes%20review_2022_WCAG.pdf">strong evidence</a> that vaping leads to harms such as poisoning, injuries, burns, toxicity, addiction and lung injury. The odds of becoming a smoker is more than three times higher for never-smokers who vape than for never-smokers who don’t vape.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/making-it-harder-to-import-e-cigarettes-is-good-news-for-our-health-especially-young-peoples-141986">Making it harder to import e-cigarettes is good news for our health, especially young people's</a>
</strong>
</em>
</p>
<hr>
<h2>What’s next?</h2>
<p>This study uses data from the first wave of the Generation Vape research project, a three-year study with Australian teenagers, young adults, parents and guardians of teenagers, and secondary school teachers. </p>
<p>It is funded by the Cancer Council NSW, federal Department of Health and Ageing, NSW Ministry of Health, Cancer Institute NSW and the Minderoo Foundation.</p>
<p>Future waves of this repeat cross-sectional study, coupled with in-depth interviews, will allow us to track and monitor changes to adolescent, young adult, teacher, and parent attitudes, perceptions, and knowledge of vaping over time. </p>
<p>Vaping is a rapidly evolving public health crisis in Australia. Our research provides evidence for concerted policy action to prevent young people from accessing harmful and addictive products. </p>
<p>Failure to act will see a whole new generation of Australians addicted to dangerous products.</p><img src="https://counter.theconversation.com/content/190669/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christina Watts has received funding from the Australian Government Department of Health and Aged Care, NSW Ministry of Health, Cancer Council NSW, Cancer Institute NSW and the Minderoo Foundation.</span></em></p><p class="fine-print"><em><span>Becky Freeman has received funding from Healthway WA, NSW Health, Australian Government of Health, Cancer Institute NSW, Ian Potter Foundation, Mindaroo Foundation, NHMRC, WHO, Cancer Council, Cancer Council NSW, Cancer Council WA, and Heart Foundation NSW. She was an expert member of the NHMRC Electronic Cigarettes Working Committee (2020-2022). She is an expert advisor to the National Tobacco Issues Committee. </span></em></p><p class="fine-print"><em><span>Sam Egger has received funding from the Australian Government Department of Health and Aged Care, NSW Ministry of Health, Cancer Council NSW, Cancer Institute NSW and the Minderoo Foundation.</span></em></p>Most teens got their vape from their friends. But of those who bought their own, one-third bought it at the servo, tobacconist or convenience store.Christina Watts, Research fellow, tobacco control, University of SydneyBecky Freeman, Associate Professor, School of Public Health, University of SydneySam Egger, Biostatistician, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1866282022-08-10T12:16:32Z2022-08-10T12:16:32ZCigarette advertising aggressively targets kids in low- and middle-income countries, a new study finds<figure><img src="https://images.theconversation.com/files/477722/original/file-20220804-1334-m15q4r.jpg?ixlib=rb-1.1.0&rect=42%2C30%2C4046%2C2642&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In some countries, cigarettes are prominently displayed at children's eye level.</span> <span class="attribution"><span class="source">Campaign for Tobacco-Free Kids</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em></p>
<h2>The big idea</h2>
<p>The world’s largest multinational tobacco companies are advertising cigarettes to kids near playgrounds and schools in 42 majority low- and middle-income countries. That’s the key finding of our <a href="http://dx.doi.org/10.1136/tobaccocontrol-2021-057095">recently published paper</a>. </p>
<p>Through our on-the-ground data collection at 19,500 points of sale, we identified tobacco industry advertising and promotions demonstrating four common tactics. These include displaying cigarettes near snacks, sweets and sugary drinks; placing cigarette advertisements near children’s eye level; marketing flavored cigarettes through ads and/or product displays; and selling single cigarette sticks. </p>
<p>We collected data on how cigarettes are marketed and sold within 250 meters, or about 820 feet, of one or more schools and/or playgrounds in more than 100 cities around the globe. The locations included most capital cities and spanned Africa, Asia, Central America, Europe, North America and South America.</p>
<p>Our findings correspond with <a href="http://dx.doi.org/10.1136/tc.2003.006577">similar research conducted in high-income countries</a>. Taken together, our research and that of others suggests that in the absence of strong restrictions and enforcement, the tobacco industry is employing similar marketing strategies all around the world with what we believe is <a href="http://dx.doi.org/10.1136/tobaccocontrol-2021-057026">the specific intention to attract</a> <a href="http://dx.doi.org/10.1136/tobaccocontrol-2015-052586">and addict</a> children and youth.</p>
<h2>Why it matters</h2>
<p>Many jurisdictions throughout the world have implemented laws <a href="https://truthinitiative.org/research-resources/tobacco-industry-marketing/what-do-tobacco-advertising-restrictions-look-today">prohibiting advertising of tobacco products</a> on radio, television and billboards. As a result, <a href="https://apps.who.int/iris/handle/10665/178574">comparably less restricted</a> point-of-sale opportunities have become a critical component of tobacco company marketing strategies. This includes the <a href="http://dx.doi.org/10.1136/tobaccocontrol-2011-050395">“Big Four” global giants</a>: Philip Morris International, British American Tobacco, Japan Tobacco International and Imperial Tobacco. </p>
<p>Previous research has established that in the face of advertising restrictions, the tobacco industry will <a href="https://ajph.aphapublications.org/doi/full/10.2105/AJPH.92.6.937">refocus its marketing efforts – and dollars</a> – on unregulated channels such as the point of sale. Tobacco companies themselves have <a href="http://dx.doi.org/10.1136/tc.2006.018978">acknowledged the effectiveness</a> of the point-of-sale channel, developing effective marketing strategies and resources geared toward maximizing potential sales. Tobacco companies <a href="http://dx.doi.org/10.1136/tobaccocontrol-2021-057026">provide incentives to retailers to market their products</a> in this manner.</p>
<p>Our findings, summarized below, show that the tobacco industry uses point-of-sale advertising widely, and consistently targets youth. </p>
<p>• In 90% of the countries we studied, cigarettes were displayed near junk food or sugary drinks, including some self-serve displays within children’s reach. </p>
<p>• We found ads or displays promoting flavored cigarettes, which are <a href="http://dx.doi.org/10.1136/tobaccocontrol-2016-053196">known to appeal to minors</a>, in 76% of the countries we studied.</p>
<p>• Stores selling tobacco in 78% of countries sold single cigarettes, <a href="https://doi.org/10.1007%2Fs11524-013-9854-3">making the product more affordable</a>. </p>
<p>• Points of sale in all 42 majority low- and middle-income countries displayed cigarette advertising at kids’ eye level, featuring “Big Four” tobacco products or ads.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/booe1PLkdGY?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The study identified four common tactics that tobacco companies use to target kids.</span></figcaption>
</figure>
<p>Research is clear that kids who are frequently exposed to tobacco advertising and promotion at points of sale have <a href="http://dx.doi.org/10.1136/tobaccocontrol-2015-052586">higher odds of trying smoking and are more likely to be susceptible</a> to smoking in the future compared to those who are less frequently exposed. Smoking kills <a href="https://www.who.int/news-room/fact-sheets/detail/tobacco">8 million people worldwide each year</a> and is the leading cause of preventable death.</p>
<p>Experts have also established links between point-of-sale advertising and smoking-related behaviors and beliefs, like misperceptions that smoking is less harmful than it really is and a <a href="https://doi.org/10.1093/ntr/ntn002">lower likelihood of quitting smoking</a>.</p>
<h2>What’s next</h2>
<p>Our work focused on what consumers see and did not differentiate between products that were on sale legally versus those sold illicitly. </p>
<p>The World Health Organization <a href="https://fctc.who.int/who-fctc/overview">Framework Convention on Tobacco Control</a>, an international treaty ratified by 182 parties and covering more than 90% of the world’s population, recommends a variety of evidence-based strategies to counteract these marketing tactics. These include comprehensive bans on tobacco advertisement, promotion and sponsorship, plain tobacco packaging, large graphic health warnings on tobacco packs, bans on single-stick cigarette sales, and regulation of flavors.</p><img src="https://counter.theconversation.com/content/186628/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This work was supported with funding from Bloomberg Philanthropies' Bloomberg Initiative to Reduce Tobacco Use (bloomberg.org). Jennifer Brown consults with the Campaign for Tobacco-Free Kids. </span></em></p>In places around the world that lack restrictions to combat the problem, tobacco companies are using marketing strategies aimed at children, like displaying tobacco products at kids’ eye level.Jennifer Brown, Researcher in Public Health, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1698422021-10-20T07:16:23Z2021-10-20T07:16:23ZWe unpack what some African countries are doing about tobacco control<figure><img src="https://images.theconversation.com/files/426410/original/file-20211014-16-smwk9i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The growth in tobacco use in Africa is a potential public health catastrophe.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Rapid <a href="https://issafrica.org/iss-today/africas-population-boom-burden-or-opportunity">population growth</a>, increased <a href="https://tobaccotactics.org/wiki/bat-africa-history-double-standards/">advertising</a> by the tobacco industry, and growing <a href="https://www.ajol.info/index.php/samj/article/view/175692">tobacco consumption</a> among young people in Africa all contribute to a projected massive tobacco-related burden of disease. The World Health Organisation (WHO) <a href="https://www.afro.who.int/health-topics/tobacco-control">estimates</a> that one in five African adolescents use tobacco. The WHO also forecast <a href="https://www.afro.who.int/health-topics/tobacco-control">a doubling</a> of deaths related to tobacco use in low- and middle-income countries between 2002 and 2030.</p>
<p>There are many efforts being made to prevent these unnecessary deaths. One of these is the establishment of the <a href="https://actd.africa/">Africa Conference on Tobacco Control and Development</a> (26-28 October 2021). The aim of the conference is to connect researchers, policymakers, advocates, students and members of the public who are interested in tobacco control on the continent. It’s a platform to share information on some of the tobacco control work conducted in Africa, reflect on lessons learned and identify what needs attention.</p>
<p>Our own contribution to the conference is <a href="http://www.reep.uct.ac.za/etcp/projects/economics-tobacco-control-project">work on the economic impacts of tobacco use</a> on the continent and beyond. </p>
<h2>Progressive developments</h2>
<p>Many African countries have indicated that they want to adopt tobacco control policies. Of the 54 countries in Africa, 51 have ratified the <a href="https://fctc.who.int/who-fctc/overview/parties">WHO Framework Convention on Tobacco Control</a> – Malawi, South Sudan and Eritrea have not. By ratifying the convention, countries commit to adopting effective and evidence-based measures to curb tobacco consumption.</p>
<p>One of the key interventions is to ban smoking in public spaces. The WHO suggests that, globally, between <a href="https://www.who.int/news-room/fact-sheets/detail/tobacco">1 million and 1.2 million deaths annually</a> are related to exposure to second-hand smoke. Thirteen African countries have <a href="https://www.who.int/publications/i/item/9789240032095">smoke-free bans</a>, joining more than 50 other countries around the world.</p>
<p>Sixteen African countries <a href="https://www.tobaccofreekids.org/assets/global/pdfs/en/WL_country_size.pdf">require</a> cigarette manufacturers to print graphic health warnings on cigarette packs. Studies have <a href="https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-018-0933-0">shown</a> that pictures of risks, like diseased lungs, reduce the attractiveness of the pack and the appeal of smoking.</p>
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Read more:
<a href="https://theconversation.com/how-ghana-is-using-graphic-pictures-to-cut-tobacco-use-116845">How Ghana is using graphic pictures to cut tobacco use</a>
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<p>In 2018 the Protocol to Eliminate Illicit Trade in Tobacco Products came into force. Countries that ratify the protocol commit themselves to adopting a variety of measures, such as using track and trace systems to prevent and counter illicit trade. Currently, 27 African countries have <a href="https://treaties.un.org/Pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IX-4-a&chapter=9&clang=_en">ratified the protocol</a>, the highest proportion of any continent. A number of countries have already implemented some of the measures suggested in the protocol.</p>
<p>Raising excise taxes is the most effective measure to <a href="https://apps.who.int/iris/rest/bitstreams/1341465/retrieve">reduce smoking</a>. Studies around the world show that excise taxes that effectively raise the price of tobacco products almost always result in a <a href="https://cancercontrol.cancer.gov/sites/default/files/2020-08/m21_complete.pdf">decline in smoking</a>. The structure of the excise tax is important. In general, a specific tax (an amount of tax per cigarette, irrespective of value) is better than an ad valorem tax (a percentage of the product’s value). Simpler tax systems are better than complex ones.</p>
<h2>Safeguarding the gains</h2>
<p>Despite the progress made in many countries, many challenges remain. One is the slow adoption of recommended tobacco tax policies.</p>
<p>Most African countries have excise tax systems that are <a href="https://www.who.int/publications/i/item/9789240032095">generally regarded</a> as sub-optimal. This is because the tax systems are usually ad valorem, tiered, or both. These factors dampen the influence of excise taxes on the price of cigarettes. It is thus unsurprising that cigarettes are relatively cheap in most African countries. In fact, the excise tax, expressed as a percentage of the average retail price, is lower in Africa than on any other continent in the world. On average, this figure stands at 28.6% in Africa, 35.4% in South America and 37.3% in Asia. </p>
<p>The excise tax systems in some countries have actually regressed. A classic example is Kenya. In the 1990s and early 2000s, Kenya had one of the most complex tax systems in Africa. This complexity allowed the tobacco industry to profit at the expense of the fiscus and of public health. Targeted campaigns by tobacco-control advocates culminated in the implementation of the WHO-recommended uniform specific excise tax in 2015. This achievement, however, was short-lived. In 2019, under pressure from the tobacco industry, the Kenyan government reintroduced a <a href="https://www.kra.go.ke/en/media-center/blog/823-sin-tax">two-tier system</a>. The two-tier system allows tobacco companies to differentiate their products just enough to maximise profits on high-end brands, while keeping low-end brands cheap enough that large numbers of people continue smoking.</p>
<p>South Africa’s tax system has also regressed. Between 1994 and 2009, South Africa’s tobacco control efforts, anchored by sharp increases in the excise tax, were praised globally. Strong administrative controls by the South African Revenue Service prevented illicit trade from increasing. Since 2010, there has been a rapid increase in illicit trade, even though excise tax increases in the past decade have been negligible. Since 2015, illicit trade in South Africa has increased substantially, and now accounts for at least <a href="https://tobaccocontrol.bmj.com/content/tobaccocontrol/29/Suppl_4/s234.full.pdf">35% of the total market</a>. The primary reason for this increase is the decline in the South African Revenue Service’s capacity to ensure tax compliance among tobacco manufacturers. The tobacco industry has been at the forefront of <a href="http://www.inqcomm.co.za/Docs/media/SARS%20Commission%20Final%20Report.pdf">undermining the revenue authority</a>. Efforts to implement a track and trace system have been unsuccessful.</p>
<p>The ethical practices of the tobacco industry have been called into question for decades. Recently, the BBC’s programme <a href="https://www.bbc.co.uk/iplayer/episode/m000zpd5/panorama-dirty-secrets-of-the-cigarette-business">Panorama</a> presented a documentary on the tobacco industry. The documentary was the culmination of <a href="https://tobaccotactics.org/wiki/the-bat-files/">years of research</a> conducted by investigative journalists and researchers at the University of Bath. It <a href="https://bat-uncovered.exposetobacco.org/">details</a> the ways in which British American Tobacco (BAT) acted unethically in various <a href="https://tobaccotactics.org/wiki/bat-africa-dirty-deeds/">African countries</a> to maintain its high profits, to block or weaken tobacco control legislation, and to maintain its market dominance. </p>
<p>This is not the first time British American Tobacco has been accused of these practices and, sadly, it is unlikely to be the last.</p><img src="https://counter.theconversation.com/content/169842/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Corné van Walbeek is the Director of the Research Unit on the Economics of Excisable Products (REEP) at the University of Cape Town. The unit is soft-funded and receives funding from a number of donor organisations, the most important of which are the Bill & Melinda Gates Foundation, the African Capacity Building Foundation, the International Development Research Centre and Cancer Research UK. His salary is paid by UCT, but he receives a modest supplement from these funding agencies. He is not affiliated to the tobacco industry. He is a non-remunerated board member of the Tobacco, Alcohol and Gambling Advisory, Advocacy and Action Group. </span></em></p><p class="fine-print"><em><span>Zunda Chisha is a research officer with the Research Unit on the Economics of Excisable Products (REEP). He is also a PhD candidate in economics at the University of Cape Town. His thesis is focused on how tobacco use and alcohol abuse affect development in South Africa. Zunda's PhD studies are funded through a scholarship provided for by the African Capacity Building Foundation (ACBF) with a grant from the Bill and Melinda Gates Foundation. He is not affiliated to the tobacco industry. </span></em></p>Globally, about 1 million deaths annually are related to exposure to second-hand smoke. Thirteen African countries have implemented comprehensive smoke-free bans.Corne van Walbeek, Professor at the School of Economics and Principal Investigator of the Economics of Tobacco Control Project, University of Cape TownZunda Chisha, Research officer, Research Unit on the Economics of Excisable Products, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1685642021-09-30T04:32:55Z2021-09-30T04:32:55ZAfter buying health company Vectura, tobacco giant Philip Morris will profit from treating the illnesses its products create<figure><img src="https://images.theconversation.com/files/423488/original/file-20210928-27-1hw03j1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/closeup-view-full-ashtray-on-table-80306686">Shutterstock</a></span></figcaption></figure><p>Cigarettes are the only legal consumer product that <a href="https://www.acosh.org/resources/big-tobacco/#:%7E:text=Tobacco%2520is%2520the%2520only%2520consumer,than%2520%252431%2520billion%2520each%2520year.">kill up to half of their users</a> when consumed exactly as the manufacturer intended. The diseases they cause cost Australia’s health system <a href="https://ndri.curtin.edu.au/NDRI/media/documents/publications/T273.pdf">A$136.9 billion</a> a year.</p>
<p>Philip Morris International (PMI) is one of the <a href="https://www.statista.com/statistics/500455/net-revenue-of-philip-morris-worldwide/">global leaders</a> in the cigarette supply chain. But with <a href="https://www.aihw.gov.au/reports/australias-health/tobacco-smoking">steady declines</a> in cigarette sales over the past 20 years, tobacco companies such as Philip Morris are now <a href="https://www.pmi.com/smoke-free-life/pmi-board-reaffirms-companys-corporate-purpose">attempting to market themselves</a> as health-care companies with visions for a “smoke-free future”. </p>
<p>One of the industry’s first moves was to <a href="https://tobaccotactics.org/wiki/e-cigarettes-industry-timeline/">manufacture</a> non-cigarette nicotine products, such as nicotine replacement therapy to help people quit smoking. </p>
<p>In the latest move to diversify its portfolio, Philip Morris has acquired British health-care company Vectura Group Plc, <a href="https://www.bmj.com/content/374/bmj.n2186">at a cost of</a> more than £1 billion (A$1.9 billion).</p>
<p><a href="https://www.vectura.com/">Vectura</a> specialises in manufacturing inhalation products such as commonly used inhalers (or puffers) and nebulisers that help people with asthma and lung disease to breathe. </p>
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Read more:
<a href="https://theconversation.com/big-tobaccos-decisive-defeat-on-plain-packaging-laws-wont-stop-its-war-against-public-health-140439">Big Tobacco's decisive defeat on plain packaging laws won't stop its war against public health</a>
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<p>On August 12, the <a href="https://www.vectura.com/wp-content/uploads/2021/08/Update-on-final-offers-for-Vectura-Group-plc.pdf">Vectura board announced</a> it “unanimously recommended the PMI offer” to shareholders, with the decision based on price and access to resources. </p>
<p>The Vectura <a href="https://www.vectura.com/wp-content/uploads/2021/08/Update-on-final-offers-for-Vectura-Group-plc.pdf">board noted</a>:</p>
<blockquote>
<p>[…] wider stakeholders could benefit from PMI’s significant financial resources and its intentions to increase research and development investment and to operate Vectura as an autonomous business unit that will form the backbone of its inhaled therapeutics business.</p>
</blockquote>
<p>On September 15, the <a href="https://www.vectura.com/wp-content/uploads/2021/08/1.-PMI-Offer-Document.pdf">deal became official</a>. And so the problems begin. </p>
<h2>Why Vectura?</h2>
<p>In acquiring Vectura, Philip Morris will <a href="https://tobaccofreeportfolios.org/wp-content/uploads/2021/08/Vectura-letter.pdf">profit from</a> treating the very illnesses its products cause, as nebulisers are commonly prescribed for patients with tobacco-related lung disease.</p>
<figure class="align-center ">
<img alt="Blue-spotted 'V' Vectura logo on a smartphone and in the background." src="https://images.theconversation.com/files/423489/original/file-20210928-24-1tnvew2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/423489/original/file-20210928-24-1tnvew2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/423489/original/file-20210928-24-1tnvew2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/423489/original/file-20210928-24-1tnvew2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/423489/original/file-20210928-24-1tnvew2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/423489/original/file-20210928-24-1tnvew2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/423489/original/file-20210928-24-1tnvew2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The Vectura takeover cost Philip Morris more than £1 billion.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/kyiv-ukraine-august-13-2021-this-2024664851">Shutterstock</a></span>
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<p>Philip Morris’s <a href="https://pmidotcom3-restricted-prd.s3.amazonaws.com/docs/default-source/restricted/pmi-press-release_vectura-tender_160921_final.pdf">interest</a> in the company is to help it generate “[…] at least $1 billion in annual net revenues from Beyond Nicotine sources in 2025”. In other words, Philip Morris plans to expand development of electronic cigarettes and start profiting from other inhaled devices.</p>
<p>This is despite there being <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/resp.13904">limited evidence</a> to support electronic cigarettes to help people quit smoking, but <a href="https://www.thoracic.org.au/documents/item/1051">mounting evidence</a> showing damaging health effects. </p>
<p>If Philip Morris really wants to move “beyond nicotine”, it should stop its <a href="https://www.tobaccofreekids.org/press-releases/2019_06_19_pmi_indonesia_israel">aggressive promotion and sale</a> of all tobacco products. </p>
<h2>Why does it matter?</h2>
<p>The consequences of Philip Morris’s acquisition of Vectura are far reaching, especially for the medical and research workforce fighting against respiratory disease. The Philip Morris takeover will have <a href="https://tobaccofreeportfolios.org/wp-content/uploads/2021/08/Vectura-letter.pdf">significant implications</a> for the sector. </p>
<p>Many public health organisations, medical professional bodies, universities, individual health professionals and researchers cannot and will not work with tobacco companies or their affiliates. This is in line with the World Health Organization’s <a href="https://www.phrp.com.au/issues/september-2020-volume-30-issue-3/the-who-framework-convention-on-tobacco-control-time-for-a-civil-society-equivalent/">Framework Convention on Tobacco Control</a>.</p>
<p>This means researchers who would have received support from Vectura, or used their products to pioneer the next generation of inhaler therapies, will no longer be able to do this. </p>
<p>There will be <a href="https://tobaccofreeportfolios.org/wp-content/uploads/2021/08/Vectura-letter.pdf">conflicts of interest</a> prohibiting them from publishing their findings, collaborating on grants for new research, and presenting their work at conferences. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/medical-journals-refuse-to-publish-tobacco-funded-research-19201">Medical journals refuse to publish tobacco-funded research</a>
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<p>This has already begun to happen, with pharmaceutical industry conferences such as the Drug Delivery to the Lungs Conference terminating Vectura’s sponsorship, forcing the company’s representative to stand down from its committee, and <a href="https://www.thetimes.co.uk/article/pharma-events-bar-vectura-after-its-takeover-by-marlboro-cigarette-maker-philip-morris-tnjbb99w2">barring them</a> from <a href="https://tobaccoreporter.com/2021/09/21/pharmaceutical-events-bann-vectura-after-pmi-takeover/">participation</a>.</p>
<p>Going forward, companies, health professionals and researchers now inadvertently linked to big tobacco through Vectura may be restricted from fully participating in the medical and scientific community. The European Respiratory Society, for example, <a href="https://d197for5662m48.cloudfront.net/documents/publicationstatus/68262/preprint_pdf/e951183cf01a391ceafcfff7bff0b266.pdf">excludes participation</a> from anyone with links to the tobacco industry in the past ten years. </p>
<p>The Pharmaceutical Benefits Scheme (PBS) will need to consider if it’s appropriate for Australian taxpayers to subsidise inhaler devices licensed to Vectura or, more truthfully, to big tobacco. </p>
<p>Many doctors will be looking for alternative devices to prescribe for their patients that do not contribute to Philip Morris’s or Vectura’s profits. </p>
<p>Meanwhile, people with lung disease are also likely to be reluctant to use <a href="https://d197for5662m48.cloudfront.net/documents/publicationstatus/68262/preprint_pdf/e951183cf01a391ceafcfff7bff0b266.pdf">devices linked to big tobacco</a>. </p>
<figure class="align-center ">
<img alt="Older man sits on the edge of his bed, breathing through a nebuliser mask." src="https://images.theconversation.com/files/423492/original/file-20210928-28-759a96.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/423492/original/file-20210928-28-759a96.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/423492/original/file-20210928-28-759a96.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/423492/original/file-20210928-28-759a96.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/423492/original/file-20210928-28-759a96.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/423492/original/file-20210928-28-759a96.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/423492/original/file-20210928-28-759a96.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Vectura makes nebulisers which help people with asthma and lung disease to breathe.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-man-inhaling-airways-lungs-applying-1959779509">Shutterstock</a></span>
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<p>But <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4671757/">switching</a> from one inhaler to another comes with consequences, such as lower adherence and new side effects, causing poorer clinical outcomes. </p>
<p>There are also concerns Philip Morris’s takeover of Vectura <a href="https://www.bmj.com/content/374/bmj.n2186">could be used</a> to buy “a seat at the table” with health care policymakers and professionals, meaning they could have a say in the development of government policies. </p>
<h2>The tobacco industry hasn’t changed</h2>
<p>The tobacco industry remains one of the world’s <a href="https://www.phrp.com.au/issues/september-2020-volume-30-issue-3/the-who-framework-convention-on-tobacco-control-time-for-a-civil-society-equivalent">most lethal</a>. And Philip Morris continues to undermine public health messages, while <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2794243/pdf/nihms155204.pdf">trying to disguise itself</a> as a health brand. </p>
<p>Yet Philip Morris’s company statutory regulations, which are the standards by which they undertake business, <a href="https://www.sec.gov/Archives/edgar/data/1413329/000141332915000016/pm12312014form10kwrapinclf.htm">list</a> evidence-based actions to reduce smoking rates – such as strong health warnings on packets and smoking bans in public places – as “risk factors” for its business. </p>
<p>Philip Morris’s move into the health sector, reinforced with the latest acquisition of Vectura, should be met with equal measures of disgust and contempt.</p><img src="https://counter.theconversation.com/content/168564/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kristin Carson-Chahhoud receives funding from The National Health and Medical Research Council, Channel 7 Children's Research Foundation, Cancer Australia, Ministry of Health, The Sax Institute, New South Wales Government, Thoracic Society of Australia and New Zealand, University of South Australia, Australian Association of Gerontology, Cancer Council Victoria, Asthma Australia, The University of Adelaide and the Australian and New Zealand School of Government. She has received honorariums and travel reimbursement from Pfizer Australia to present her research findings at the Pfizer annual general meeting and at the Ogilvy Smoking Exchange Summit. Kristin is a Board Director for the Thoracic Society of Australia and New Zealand (TSANZ), Chair of the TSANZ Research Subcommittee and Executive Director of the SA/NT Branch of the TSANZ. She is also a member of the Australian Association of Gerontology.</span></em></p><p class="fine-print"><em><span>Bruce Thompson is immediate past president of the Thoracic Society of Australia and New Zealand. He has received research funding from the NHMRC, and historically speaker fees from Chiesi, Mundipharma, GSK and AstraZenca.</span></em></p><p class="fine-print"><em><span>John Upham has received funding from the National Health & Medical Research Council. He is currently President of the Thoracic Society of Australia and New Zealand.</span></em></p>Tobacco giant Philip Morris has acquired British company Vectura, which make puffers and nebulisers that help people with lung disease to breathe.Kristin Carson-Chahhoud, Associate Research Professor, University of South AustraliaBruce Thompson, Professor and Dean of the School of Health Sciences, Swinburne University of TechnologyJohn Upham, Professor of Respiratory Medicine, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1464182020-10-14T13:46:32Z2020-10-14T13:46:32ZNew evidence shows e-cigarettes can help people quit smoking<figure><img src="https://images.theconversation.com/files/363178/original/file-20201013-13-1r1zvrg.jpg?ixlib=rb-1.1.0&rect=0%2C7%2C5332%2C3536&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/grey-pink-vape-pen-held-by-1281247297">A McCormack/Shutterstock</a></span></figcaption></figure><p>Electronic cigarettes, or e-cigarettes, are a <a href="https://edition.cnn.com/2019/10/21/health/e-cigarettes-quit-smoking-uk-study/index.html">popular aid for quitting smoking</a>, but it is taking time for scientific research to catch up and provide clear answers on how well they work, and whether they are safe to use for this purpose. </p>
<iframe id="noa-web-audio-player" style="border: none" src="https://embed-player.newsoveraudio.com/v4?key=x84olp&id=https://theconversation.com/new-evidence-shows-e-cigarettes-can-help-people-quit-smoking-146418&bgColor=F5F5F5&color=D8352A&playColor=D8352A" width="100%" height="110px"></iframe>
<p>An <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010216.pub4/full">updated review</a> of the evidence, covering 50 studies and more than 12,000 participants, now provides greater confidence that e-cigarettes with nicotine can help more people to quit smoking than traditional nicotine replacement therapy (such as gums or patches) or e-cigarettes without nicotine. However, the evidence is of moderate certainty – and more studies are needed to confirm the degree of effect, particularly testing newer e-cigarette devices.</p>
<p>The review found no evidence of serious harms of e-cigarettes with nicotine. But the data was limited – the longest follow-up was just two years – and considerable uncertainty remains regarding harms.</p>
<p>Smoking kills <a href="https://www2.hse.ie/wellbeing/quit-smoking/reasons-to-quit-smoking/smoking-facts-and-figures.html">one in two</a> regular users. Most people who smoke <a href="https://truthinitiative.org/research-resources/quitting-smoking-vaping/what-you-need-know-quit-smoking#:%7E:text=Most%20smokers%20%E2%80%94%20nearly%2070%20percent,from%2050.8%20percent%20in%202005.">want to quit</a>, but quitting smoking can be extremely difficult, and better treatments are needed. </p>
<p>For many, the arrival of e-cigarettes signalled an exciting opportunity. E-cigarettes represented a new treatment for cigarette addiction, mimicking some of the <a href="https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-018-0237-7">behavioural, social and pharmacological aspects of cigarettes</a>. But some policymakers remain cautious, despite the increase in research findings that support e-cigarettes for quitting smoking. </p>
<p>Whereas e-cigarettes are widely available in some countries, in other areas current policies include <a href="https://theconversation.com/an-increasing-number-of-countries-are-banning-e-cigarettes-heres-why-123055">complete bans on e-cigarettes</a> and policies in which e-cigarettes with nicotine are <a href="https://www.theguardian.com/society/2020/sep/23/e-cigarettes-to-become-available-as-prescription-only-items-in-australia-from-june-2021">available on prescription only</a>.</p>
<p>The caution behind restrictive regulations is not to do with whether people who smoke should switch to e-cigarettes. While there are still unknowns regarding possible longer-term harms of e-cigarettes, <a href="https://pubmed.ncbi.nlm.nih.gov/29894118/">experts generally agree</a> that e-cigarettes are considerably less harmful than smoking, even though they are not completely risk free. </p>
<p><a href="https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html">Evali</a>, the e-cigarette-related illness that made headlines last year, raised significant concerns around the safety of e-cigarettes. But it was quickly discovered that <a href="https://www.nejm.org/doi/full/10.1056/NEJMsr1915313">this was linked to vitamin E acetate</a> – an additive that has been found in unregulated e-cigarette liquids, typically containing THC (the active ingredient in cannabis). This additive is banned from e-cigarettes in many parts of the world, including Europe. </p>
<figure class="align-center ">
<img alt="Two vape pens containing cannabis oil." src="https://images.theconversation.com/files/363196/original/file-20201013-19-1g09qbp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/363196/original/file-20201013-19-1g09qbp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/363196/original/file-20201013-19-1g09qbp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/363196/original/file-20201013-19-1g09qbp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/363196/original/file-20201013-19-1g09qbp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/363196/original/file-20201013-19-1g09qbp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/363196/original/file-20201013-19-1g09qbp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The illness Evali was related to vaping cannabis oil containing vitamin E acetate.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/two-full-gram-cannabis-oil-vape-1296915751">Shannon L Price/Shutterstock</a></span>
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<p>Caution, instead, largely has to do with how the availability of e-cigarettes affects young people. Young people who use e-cigarettes are <a href="https://jamanetwork.com/journals/jamapediatrics/fullarticle/2634377">more likely to go on to smoke</a>. Some interpret this data to mean that young people who would never smoke experiment with e-cigarettes become addicted to nicotine and then start smoking. In other words, some argue that e-cigarettes act as a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6468127/">gateway</a> to smoking tobacco. Others argue that the link is instead due to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3982606/">commonalities between young people</a> who would try e-cigarettes and try smoking regardless – the idea that: “kids who try things, try things”. While research is ongoing on this, debates on policy divide into “help the adults quit” and “protect the kids”. </p>
<h2>Not mutually exclusive</h2>
<p>Helping adults quit and protecting kids are not mutually exclusive. Children whose parents smoke are around <a href="https://ash.org.uk/category/information-and-resources/young-people-tobacco-information-and-resources/">three times more likely</a> to smoke in later life. Whereas secondhand smoke is known to cause <a href="https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/health_effects/">many health problems</a> in infants and children, including sudden infant death syndrome, the <a href="https://www.bmj.com/content/370/bmj.m3529#ref-1">harm of e-cigarette vapour to bystanders</a> appears far less than that from cigarettes. </p>
<p>By acknowledging that helping adults quit smoking is also a way to protect kids, it may be possible to move the debate along. This is needed to craft regulations that both prevent young people from starting to use e-cigarettes <em>and</em> from starting to smoke, and help the adults around them to stop smoking. One approach that has been tried is to reduce the amount of nicotine in e-cigarettes. But studies have shown that this may have unintended effects – people who smoke seem to <a href="https://pubmed.ncbi.nlm.nih.gov/29882257/">puff harder on e-cigarettes</a> with a lower nicotine content to get the nicotine levels they seek. </p>
<p>Nicotine is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3982606/">not the chemical</a> that causes the many diseases linked to smoking. In fact, nicotine replacement therapy, which provides nicotine without the other harmful chemicals from cigarettes, has been available to help people safely stop smoking for decades. Despite its wide availability, there is very little evidence that non-smokers use it. This is down to a combination of factors, but marketing and regulation have undoubtedly played important roles. </p>
<p>The regulation of e-cigarette sales and marketing varies substantially worldwide. Though this muddies the waters when communicating potential benefits and harms of e-cigarettes, <a href="https://jamanetwork.com/journals/jamapediatrics/article-abstract/2765159">regional differences</a> in e-cigarette use among young people may help guide effective regulation in the future. For example, researchers and policymakers can look to areas where e-cigarette use in young people is low and compare regulations to those in place in areas where e-cigarette use in young people is more widespread. Ideally, lessons could be learned about ways to ensure e-cigarettes are readily available to people struggling to quit smoking, but are not appealing to people who don’t smoke.</p>
<p>The tension between “protecting the kids” and “helping adults who smoke” has been getting in the way of clear public health messaging for years. As new evidence emerges, the message remains the same: e-cigarettes with nicotine are not risk free but are considerably less harmful than smoking. Translated into actions: if you don’t smoke, don’t start to use e-cigarettes. If you do smoke, consider switching.</p><img src="https://counter.theconversation.com/content/146418/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jamie Hartmann-Boyce receives funding from the National Institute for Health Research, British Heart Foundation, and Cancer Research UK. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.</span></em></p><p class="fine-print"><em><span>Nicola Lindson receives funding from the National Institute for Health Research and Cancer Research UK. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.. </span></em></p>Yet regulators remain torn.Jamie Hartmann-Boyce, Senior Research Fellow, Departmental Lecturer and Director of Evidence-Based Healthcare DPhil Programme, Centre for Evidence-Based Medicine, University of OxfordNicola Lindson, University Research Lecturer, Nuffield Department of Primary Care Health Sciences, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1449342020-09-16T06:06:17Z2020-09-16T06:06:17ZRatifying WHO’s Framework Convention on Tobacco Control could help Indonesia reduce tobacco imports, benefitting local tobacco farmers<p>Indonesia has more than 60 million smokers and one of the highest smoking rates in the world, but is <a href="https://www.fctc.org/parties-ratifications-and-accessions-latest/">one of nine countries </a>yet to sign or ratify the Framework Convention on Tobacco Control (FCTC). This treaty, negotiated under the auspices of the World Health Organisation, enforces signing parties to suppress tobacco consumption within their countries.</p>
<p>This reluctance is driven by <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7168953/">myriad reasons</a>, including fear such controls <a href="https://seatca.org/dmdocuments/Indonesia%20TII%20in%20Tax.pdf">would harm the welfare of local tobacco farmers</a>. </p>
<p>In fact, our research <a href="https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-020-00595-y">shows</a> tobacco imports are the primary threat for Indonesian tobacco farmers. </p>
<p>Our observation of other four countries that have ratified the FCTC - Bangladesh, Mozambique, Pakistan, and Zimbabwe - showed the treaty would, in fact, control tobacco imports (as well as reducing overall tobacco consumption).</p>
<h2>Research findings</h2>
<p>We conducted our research in 2019 by analysing Indonesian tobacco farming data from 1990 – 2016.</p>
<iframe src="https://flo.uri.sh/visualisation/3748856/embed" frameborder="0" scrolling="no" style="width:100%;height:600px;" aria-label="" width="100%" height="400"></iframe>
<div style="width:100%!;margin-top:4px!important;text-align:right!important;"><a class="flourish-credit" href="https://public.flourish.studio/visualisation/3748856/?utm_source=embed&utm_campaign=visualisation/3748856" target="_top"><img alt="Made with Flourish" src="https://public.flourish.studio/resources/made_with_flourish.svg"> </a></div>
<p>We found Indonesia relies heavily on imported tobacco products (including Virginia tobacco leaves from China, Brazil and the US), at the expense of local producers.</p>
<p>While the local production growth is <a href="http://ditjenbun.pertanian.go.id/?publikasi=buku-statistik-kelapa-sawit-palm-oil-2011-2013">stagnant</a> with an average growth of 1.65% over 27 years, tobacco imports into Indonesia have grown by more than double since 1990. </p>
<p>Higher import leads to lower demand for local tobacco products, which disadvantages local tobacco farmers. </p>
<p>While Indonesia still struggles to control tobacco imports that hurt local farmers, some large tobacco market countries such as Zimbabwe, Mozambique, Pakistan and Bangladesh have, in fact, boosted local tobacco production after ratifying the FCTC. Tobacco imports to these nations fell after the treaty was ratified.</p>
<p>There are at least two ways the FCTC could control tobacco imports. </p>
<p>Firstly, the FCTC promotes high tobacco taxes, including import tariffs. Higher import tariffs will limit tobacco imports.</p>
<p>Secondly, the FCTC reduces local tobacco consumption. Once the local demand drops, tobacco imports will follow suit as decreased demand for cigarettes will decrease the demand for tobacco leaves. Hence, the demand for imported tobacco leaves will also decrease. Our studies of the four countries have also proven this. </p>
<h2>The story of four countries</h2>
<p>Despite the relatively high local tobacco production, the four countries we looked at managed to keep the import-to-export ratio low. </p>
<p>Zimbabwe, one of the world’s highest tobacco exporters with nearly <a href="http://www.fao.org/faostat/en/#data">92% of its tobacco production exported</a>, ratified the FCTC in 2014. Cigarettes in Zimbabwe became less affordable between 2014 and 2016 following the implementation of <a href="https://www.researchgate.net/publication/290212632_Tobacco_is_our_industry_and_we_must_support_it_Exploring_the_potential_implications_of_Zimbabwe's_accession_to_the_Framework_Convention_on_Tobacco_Control">higher tobacco taxes</a>. The higher tobacco taxes lower cigarette consumption, which eventually cut imports.</p>
<p>This also applies to Mozambique, a <a href="https://trendeconomy.com/data/h2/Mozambique/TOTAL">net tobacco exporting country</a>. Mozambique was able to increase cigarette prices by 85% after signing the FCTC. Increasing cigarette prices lead to declining local tobacco demand and hence reduces demand for tobacco imports.</p>
<p>Bangladesh is known for its <a href="https://idl-bnc-idrc.dspacedirect.org/bitstream/handle/10625/42636/129941.pdf">alternative to tobacco agriculture</a>. Bangladeshi tobacco farmers switched from tobacco to food crops such as potato, melon and French bean. Bangladesh ratified the FCTC in 2005. Since then, the country has significantly reduced smoking prevalence from <a href="https://data.worldbank.org/indicator/SH.PRV.SMOK">28.2% in 2005 to 23%</a> following the issuance of the country’s 2005 Tobacco Control Law after the ratification. The law imposed higher tobacco taxes, which reduces consumption. A decline in tobacco consumption leads to lower tobacco imports. </p>
<p>Pakistan ratified the FCTC in 2004 and is relatively <a href="https://www.who.int/tobacco/surveillance/policy/country_profile/pak.pdf?ua=1">strict</a> in the implementation of the treaty’s protocols. Of the countries we looked at, Pakistan is the only one to fully implement policies on smoke-free environments, health warnings and anti-tobacco campaigns.</p>
<p>This allows Pakistan to reduce <a href="https://data.worldbank.org/indicator/SH.PRV.SMOK">tobacco use from 22.7% in 2005 to 20.1% in 2016 </a>. The decline in tobacco consumption makes it easier for Pakistan <a href="https://trendeconomy.com/data/h2/Pakistan/2401">to control tobacco import growth</a> as the demand for local and imported products in Pakistan declines. Pakistan tobacco imports contributed to only <a href="http://www.fao.org/faostat/en/#data">1.7%</a> of local consumption in 2016.</p>
<h2>Recommendation</h2>
<p>The lack of tobacco control has burdened Indonesia’s economy. Rising tobacco consumption has led to increased tobacco imports. </p>
<p>Ratifying the FCTC could fix this. Our research on four other countries that have ratified the convention shows how these countries controlled tobacco consumption and reduced their tobacco imports. </p>
<p>Ratifying the FCTC is one of the most effective ways to reduce tobacco imports as it also enforces the implementation of tobacco import tariffs. </p>
<p>By ratifying the convention, Indonesia would not only help local tobacco farmers by enforcing import tariffs but also control tobacco consumption.</p>
<p><em>Nadira Amalia from University of Malaya in Malaysia has contributed to this article</em></p><img src="https://counter.theconversation.com/content/144934/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Abdillah Ahsan menerima dana dari South East Asia Tobacco Control Alliance dan Universitas Indonesia . </span></em></p>Our research found Indonesia relies heavily on imported tobacco products, at the expense of local producers.Abdillah Ahsan, Lecturer, Universitas IndonesiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1413882020-06-24T12:11:35Z2020-06-24T12:11:35ZPasha 69: Five ways to stop young people from smoking<figure><img src="https://images.theconversation.com/files/343701/original/file-20200624-132988-1mt8y40.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> </figcaption></figure><p>Most adult smokers take up the habit before the age of 20. So, if governments can prevent young people from smoking, it’s likely they won’t smoke in adulthood. To ensure a smoke-free future, governments should aim anti-smoking campaigns at young people. But how can they go about this? </p>
<p>To answer this question, this episode’s guests are Corné van Walbeek, a professor at the University of Cape Town’s School of Economics and principal investigator of the Economics of Tobacco Control Project, and Sam Filby, researcher on the Economics of Excisable Products, at the same university. </p>
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Read more:
<a href="https://theconversation.com/young-people-are-key-to-a-nicotine-free-future-five-steps-to-stop-them-smoking-139682">Young people are key to a nicotine-free future: five steps to stop them smoking</a>
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<p><strong>Photo:</strong>
“Poster, banner or flyer design for World No Tobacco Day with illustration anti smoking symbol on human hand” By Allies Interactive <a href="https://www.shutterstock.com/image-vector/poster-banner-flyer-design-world-no-192651830">Shutterstock</a></p>
<p><strong>Music</strong>
“Happy African Village” by John Bartmann, found on <a href="http://freemusicarchive.org/music/John_Bartmann/Public_Domain_Soundtrack_Music_Album_One/happy-african-village">FreeMusicArchive.org</a> licensed under <a href="https://creativecommons.org/publicdomain/zero/1.0/">CC0 1</a>.</p>
<p>“Ambient electronic music 001” by Frankum found on <a href="https://freesound.org/people/frankum/sounds/328368/">Freesound</a> licensed under <a href="http://creativecommons.org/publicdomain/zero/1.0/">Creative Commons license</a></p><img src="https://counter.theconversation.com/content/141388/count.gif" alt="The Conversation" width="1" height="1" />
Here are 5 ways governments can get young people off tobacco.Ozayr Patel, Digital EditorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1405532020-06-15T20:01:57Z2020-06-15T20:01:57ZAustralia’s decisive win on plain packaging paves way for other countries to follow suit<p>The decision, <a href="https://www.wto.org/english/news_e/news20_e/435_441abr_e.htm">handed down on June 9 by the World Trade Organisation’s appeals body</a>, that Australia’s plain packaging tobacco control policy doesn’t flout WTO laws marks the end of almost a decade of legal wrangling over this landmark public health policy. And more importantly, it paves the way for other nations around the world to follow Australia’s lead.</p>
<p>In 2012 Australia became the first country in the world to implement <a href="https://www.legislation.gov.au/Details/C2011A00148">tobacco plain packaging laws</a>, having recognised that the tobacco industry uses packaging both to market cigarettes and to undermine health warnings. </p>
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<a href="https://theconversation.com/the-olive-revolution-australias-plain-packaging-leads-the-world-8856">The Olive Revolution: Australia's plain packaging leads the world</a>
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<p>The industry has long acknowledged the powerful role of packaging design in attracting consumers and reinforcing brand image. A <a href="https://www.printinnovationasia.com/single-post/2017/01/18/The-Premiumisation-of-Cigarette-Packaging-in-Indonesia">2017 trade article</a> on the “premiumisation” of cigarettes explained the rationale behind glossy packaging:</p>
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<p>Features such as velvet touch, soft touch, etching, rise and relief can be applied across the surface of the packaging to make the product more impactful and raise customer engagement. The look of the packaging such as intense metallics through the use of foil simulation inks can also give cigarette packaging the luxurious effect and adds on to the premium feel of the product.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/c_z-4S8iicc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">A Cancer Research UK video shows how children react to glossy cigarette packs.</span></figcaption>
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<p>The “plain packaging” mandated by Australia’s laws is in fact anything but. It features <a href="https://www.health.gov.au/health-topics/smoking-and-tobacco/tobacco-control/tobacco-plain-packaging">graphic, full-colour health warnings</a> presented on a drab brown background. Brand logos, designs, emblems, and slogans are banned; product brand names remain, but must appear in a standardised font. </p>
<p>The result means tobacco packages can no longer serve as mini billboards that make cigarettes look aspirational and desirable.</p>
<h2>Legal challenges</h2>
<p>The tobacco industry launched three separate legal challenges to the law. First, JT International and British American Tobacco filed a lawsuit in the Australian High Court. Next, tobacco firm Philip Morris sought legal protection for its packaging designs under an existing investment treaty between Australia and Hong Kong. Finally, the industry filed a dispute through the WTO on behalf of four tobacco-producing countries: Cuba, Honduras, Indonesia and the Dominican Republic.</p>
<p>In 2012 the High Court <a href="https://www.tobaccocontrollaws.org/litigation/decisions/au-20121005-jt-intl.-and-bat-australasia-l">ruled in favour of the Australian government</a>, and in 2015 the investment treaty tribunal <a href="https://www.tobaccocontrollaws.org/litigation/decisions/au-20151217-philip-morris-asia-v-australia">dismissed Philip Morris Asia’s claim</a>. The WTO also <a href="https://www.reuters.com/article/us-wto-tobacco-ruling/australia-wins-landmark-wto-ruling-on-plain-tobacco-packaging-idUSKBN1JO2BF">ruled in Australia’s favour</a> in 2018, but the Dominican Republic and Honduras appealed. </p>
<p>That appeal was denied last week, meaning all legal challenges to Australia’s plain packaging laws have now been finally and decisively overruled – more than a decade after the then Prime Minister Kevin Rudd <a href="https://tobaccolabels.ca/australia-announces-plain-packaging/">first announced the policy</a> in April 2010.</p>
<h2>No more industry blocking</h2>
<p>The <a href="https://www.wto.org/english/tratop_e/dispu_e/435_441abr_conc_e.pdf">WTO’s appeal body agreed</a> plain packaging laws are likely to improve public health and that they are not unfairly restrictive to trade. </p>
<p>The appeal was not expected to succeed, so the ruling comes as no surprise. But despite this, legal wrangling has become a <a href="https://untobaccocontrol.org/kh/legal-challenges/court-cases-litigation-policy-brief/">standard tobacco industry practice</a>, particularly through international channels such as the WTO. One reason is because the slow and cumbersome legal process can serve as a deterrent to other countries, who may hold off implementing similar laws until the legal outcome is known.</p>
<p>Encouragingly, this stalling tactic seems to be losing its power. Countries such as France, the United Kingdom, Ireland, Norway, and New Zealand have all forged ahead with plain packaging legislation despite the outstanding appeal. </p>
<p>Now, however, lower-income countries can also confidently pursue plain packaging measures <a href="https://www.mccabecentre.org/news-and-updates/tobacco-plain-packaging-legal-victory-for-australia.html">without fear of falling foul of the WTO</a>. </p>
<h2>What next?</h2>
<p>Australia’s plain packaging law was groundbreaking at the time. But now the tobacco industry has responded with a range of tactics to exploit loopholes and offset the impact on their brands, meaning governments need to come up with yet more countermeasures.</p>
<p>Once plain packaging was implemented, the tobacco industry quickly trademarked new brand names, such as Imperial Tobacco’s <a href="https://open.sydneyuniversitypress.com.au/9781743323977/rtec-the-future.html">Peter Stuyvesant + Loosie</a>, which contains 21 cigarettes instead of 20, and advertises the bonus cigarette within the name.</p>
<p>Canada’s <a href="https://www.cancer.ca/en/about-us/for-media/media-releases/national/2019/plain-packaging-regulations/?region=qc">plain packaging laws</a>, enacted in February 2020, directly control the size and shape of the cigarettes themselves. For example, the law bans slim cigarettes targeted at young women who associate smoking with slimness and fashion. </p>
<p>Widespread plain packaging could also help curb the <a href="https://theconversation.com/big-tobacco-wants-social-media-influencers-to-promote-its-products-can-the-platforms-stop-it-129957">uprise in tobacco marketing via social media influencers</a>. A tobacco pack covered in gruesome disease imagery doesn’t make for inspiring social media content.</p>
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Read more:
<a href="https://theconversation.com/big-tobacco-wants-social-media-influencers-to-promote-its-products-can-the-platforms-stop-it-129957">Big Tobacco wants social media influencers to promote its products – can the platforms stop it?</a>
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<p>The WTO upheld Australia’s plain packaging laws because the government had convincing public health research to show the positive impact of plain packaging on public attitudes to smoking. </p>
<p>Seen in that light, the decision isn’t just a win for public health. It’s also an encouraging sign that evidence-based policies can defeat even the deepest of corporate pockets.</p><img src="https://counter.theconversation.com/content/140553/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Becky Freeman has received funding from NHMRC, WHO, the Australian Government, Australian National Preventive Health Agency, NSW Health, Cancer Council Australia, Cancer Council NSW, NSW National Heart Foundation, Cancer Council Victoria, Healthway WA, Cancer Institute New South Wales, and the Australia-Indonesia Centre.</span></em></p>The World Trade Organisation has thrown out the final legal challenge to Australia’s tobacco plain packaging laws. Now countries across the world can implement this game-changing public health policy.Becky Freeman, Senior Research Fellow, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1396902020-05-30T08:46:21Z2020-05-30T08:46:21ZTobacco bans during lockdown should encourage renewed anti-smoking drives<figure><img src="https://images.theconversation.com/files/338542/original/file-20200529-96713-qo3omb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Christian Ohde/McPhoto/ullstein bild via Getty Images</span></span></figcaption></figure><p>The 2020 World No Tobacco Day is unique and historic as it comes at the time when countries across the world are on lockdown due to the COVID-19 pandemic. </p>
<p>For Botswana the day is particularly poignant. The country has banned imports and sales of tobacco or tobacco-related products along with other emergency regulations during the country’s declared six-month <a href="https://iharare.com/botswana-national-lockdown/">state of public emergency</a>. </p>
<p>To the best of my knowledge <a href="https://africanbusinessmagazine.com/sectors/commodities/covid-19-threatens-southern-africas-tobacco-industry/">Botswana</a> and neighbouring <a href="https://www.bbc.com/news/world-africa-52772186">South Africa</a> are the only countries to have done so. Governments in both countries have faced a massive backlash, with smokers expressing their <a href="https://mg.co.za/coronavirus-essentials/2020-05-15-those-who-zol-dangerous-discourses-in-a-time-of-crisis/">unhappiness</a>. The prohibition and the response have attracted global <a href="https://www.bbc.com/news/world-africa-52772186">headlines</a>.</p>
<p>The motivation to ban the sales of tobacco and tobacco related products in Botswana was informed by <a href="http://www.tobaccoinduceddiseases.org/COVID-19-and-smoking-A-systematic-review-of-the-evidence,119324,0,2.html">scientific evidence</a> that smoking damages human lungs and other body organs. As COVID-19 is primarily a disease affecting the respiratory system, smokers are therefore <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7103991/">more vulnerable</a>.</p>
<p>Another motivation has been the actions of tobacco companies. In recent months, the industry has stooped to new lows to target youth by exploiting the pandemic to sell <a href="https://www.tobaccofreekids.org/media/2020/2020_05_covid-marketing">more products</a>. In more than 28 countries, tobacco and e-cigarette companies have used social media and other marketing tactics to launch <a href="https://www.tobaccofreekids.org/media/2020/2020_05_covid-marketing">pandemic-themed</a> promotions, undermine minimum age purchase restrictions meant to protect youth and make unproven and illegal health claims.</p>
<p>Botswana has a very high smoking rate of <a href="https://www.who.int/tobacco/surveillance/policy/country_profile/bwa.pdf?ua=1">18%</a> – <a href="https://www.afro.who.int/sites/default/files/2019-01/Botswana_GATS_2017_FactSheet_Final.pdf">27% of males and 9% of females currently use tobacco</a>. This is similar to South Africa, where the national smoking <a href="https://pubmed.ncbi.nlm.nih.gov/26449697">prevalence</a> is about 18%: 29% of males and 6.8% of females.</p>
<p>These figures are higher than the rest of the continent, where <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0132401">about</a> 14% of men and 2% of women smoke. According to the estimates by the <a href="https://www.who.int/gho/tobacco/use/en/">World Health Organisation (WHO)</a>, Africa is one of two regions – along with the Eastern Mediterranean region – where smoking rates are on the rise.</p>
<p>At a time when COVID-19 is gripping the world, the pandemic should encourage countries to kickstart programmes and policies that encourage smokers to quit. The justifications behind the bans should be used in other countries to encourage smokers to quit. Along with the measures to ban tobacco imports and sales, governments have the opportunity to provide smokers with treatments to help them. </p>
<h2>The evidence</h2>
<p>On account of the devastating impact of smoking on COVID-19, the WHO has put out a scientific <a href="https://www.who.int/news-room/detail/11-05-2020-who-statement-tobacco-use-and-covid-19">brief</a> based on a review of 32 studies. It notes that</p>
<blockquote>
<p>smoking is associated with increased severity of disease and death in hospitalised COVID-19 patients.</p>
</blockquote>
<p>The WHO’s recommendation based on the review is that given the well-established harm associated with tobacco use and second-hand smoke exposure, “tobacco users stop using tobacco”. </p>
<p>Botswana needs to jump on to this opportunity. Never before have smokers had this kind of opportunity to quit. The government must facilitate quitting by providing smoking cessation programmes. </p>
<p>The WHO <a href="https://www.who.int/tobacco/quitting/summary_data/en/">advises</a> governments to support users wanting to quit. Interventions it recommends include toll-free quit lines, mobile text-messaging cessation programmes, nicotine replacement therapies and other approved medications.</p>
<p>Countries should take their lead from the global health body. The ban on the sale of tobacco products and any calls by governments for smokers to quit during the COVID-19 pandemic need to be accompanied by initiatives that aid smokers in this course of action.</p>
<p>Additionally, and in line with the ideals of the 2020 World No Tobacco Day, the government of Botswana must strictly enforce the provisions of its Control of Smoking Act. Section 13 of the act bans the advertisement of tobacco products by the tobacco industry. </p>
<p>Recently there has been an upsurge in advertisements, especially banners posted by tobacco companies or individuals that boldly advertise and promote tobacco products in the face of COVID-19. These actions disregard existing law prohibiting the advertising and promotion of tobacco products in Botswana.</p>
<p>A survey done in South Africa of how <a href="http://www.reep.uct.ac.za/sites/default/files/image_tool/images/405/Publications/reports/Lockdown%20Survey%20Final.pdf">smokers</a> are coping with the ban on cigarette sales during lockdown confirms how difficult it is for smokers once they are caught in addiction. Governments should recognise this and accept that smokers need help to quit. This should includes counselling and nicotine replacement therapies. </p>
<p>Such strategies will counter the tobacco industry’s strategies to negate government tobacco control efforts.</p><img src="https://counter.theconversation.com/content/139690/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bontle Mbongwe does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>According to the estimates by the World Health Organisation, Africa is one of two regions – along with the Eastern Mediterranean region – where smoking rates are on the rise.Bontle Mbongwe, Associate Professor, University of BotswanaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1283002020-03-01T19:03:49Z2020-03-01T19:03:49ZSmallpox, seatbelts and smoking: 3 ways public health has saved lives from history to the modern day<figure><img src="https://images.theconversation.com/files/317706/original/file-20200228-24659-1k420tz.jpg?ixlib=rb-1.1.0&rect=9%2C9%2C5997%2C3998&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The coronovirus outbreak has reminded us of the importance of public health responses in managing the spread of disease.</p>
<p>But what actually is public health? And why are we so often hearing from public health experts about the coronavirus and other health threats?</p>
<p>In broad terms, whereas medicine primarily focuses on treating disease in individuals, public health focuses on preventing disease and improving health in communities.</p>
<p>Public health activities are far-reaching and varied. They include health promotion campaigns, infectious disease surveillance and control (as in the response to coronavirus), ensuring access to clean air, water and safe food, screening for disease, community health interventions and policy and planning activities.</p>
<p>Here are three examples which show the important role public health plays.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/its-now-a-matter-of-when-not-if-for-australia-this-is-how-were-preparing-for-a-jump-in-coronavirus-cases-132448">It's now a matter of when, not if, for Australia. This is how we're preparing for a jump in coronavirus cases</a>
</strong>
</em>
</p>
<hr>
<h2>The reduction of vaccine-preventable diseases</h2>
<p>The development of vaccines to protect against infectious diseases is one of the most significant achievements in both medicine and public health. Vaccines have prevented <a href="https://www.who.int/publications/10-year-review/vaccines/en/">literally millions of deaths</a> – the World Health Organisation (WHO) estimates at least ten million globally between 2010 and 2015 – and spared countless others from getting sick.</p>
<p>We now rarely see diseases such as polio, measles and mumps in the developed world thanks to the effectiveness of vaccines. The fact we can protect individuals and communities against some of the deadliest diseases by a simple and safe injection is one of the miracles of modern medicine.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/317704/original/file-20200228-24664-1lxyokq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/317704/original/file-20200228-24664-1lxyokq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=470&fit=crop&dpr=1 600w, https://images.theconversation.com/files/317704/original/file-20200228-24664-1lxyokq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=470&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/317704/original/file-20200228-24664-1lxyokq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=470&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/317704/original/file-20200228-24664-1lxyokq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=590&fit=crop&dpr=1 754w, https://images.theconversation.com/files/317704/original/file-20200228-24664-1lxyokq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=590&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/317704/original/file-20200228-24664-1lxyokq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=590&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A vaccine for smallpox became available in the 19th century.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>The delivery of vaccines to communities throughout the world and the reduction in disease as a result of this is a testament to public health and its power.</p>
<p>Perhaps the greatest example of the effect vaccines have had on the health of populations globally is the eradication of smallpox. A viral disease characterised by fever and a pustular rash, smallpox was one of the most devastating infectious diseases we’ve ever seen. It killed around <a href="https://www.bbc.co.uk/history/british/empire_seapower/smallpox_01.shtml">300 million people</a> in the 20th century alone.</p>
<p>To eradicate smallpox, public health physicians sought to identify new cases swiftly. Then people the cases had come into contact with were vaccinated as quickly as possible to prevent the disease spreading further, a public health measure called “<a href="https://www.cdc.gov/smallpox/bioterrorism-response-planning/public-health/ring-vaccination.html">ring vaccination</a>”. This campaign began in earnest in 1967, with the WHO declaring smallpox eradicated <a href="https://www.historyofvaccines.org/content/articles/disease-eradication">in 1980</a>, in what’s regarded as one of the greatest public health achievements of modern times.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-which-vaccinations-should-i-get-as-an-adult-81400">Health Check: which vaccinations should I get as an adult?</a>
</strong>
</em>
</p>
<hr>
<h2>Tobacco control</h2>
<p>Although there’s still a lot of work to do, smoking rates have <a href="https://www.who.int/gho/tobacco/use/en/">declined</a> over recent decades, with great benefits to our health.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/317708/original/file-20200228-24694-2ljzs9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/317708/original/file-20200228-24694-2ljzs9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=902&fit=crop&dpr=1 600w, https://images.theconversation.com/files/317708/original/file-20200228-24694-2ljzs9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=902&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/317708/original/file-20200228-24694-2ljzs9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=902&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/317708/original/file-20200228-24694-2ljzs9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1133&fit=crop&dpr=1 754w, https://images.theconversation.com/files/317708/original/file-20200228-24694-2ljzs9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1133&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/317708/original/file-20200228-24694-2ljzs9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1133&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">It’s been compulsory to wear a seatbelt in Australia since the 1970s.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>When science established a clear link between <a href="https://www.theguardian.com/news/2005/jun/02/thisweekssciencequestions.cancer">smoking and poor health outcomes</a>, the role of public health was to get this message out to the public and implement measures to minimise smoking rates.</p>
<p>We’ve managed to reduce deaths due to tobacco through interventions such as <a href="https://www.cancer.nsw.gov.au/how-we-help/cancer-prevention/stopping-smoking/quit-smoking-campaigns">health promotion campaigns</a> providing information to the public about the dangers of smoking, restrictions on cigarette advertising, plain packaging, restrictions on smoking in public places, increased taxes on cigarettes, as well as increased access to cessation programs. </p>
<p>Tobacco control is one of the major achievements of public health. This is especially true as we’ve often had to fight against the industry, or “big tobacco”, to get these initiatives off the ground.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/can-we-trust-big-tobacco-to-promote-public-health-74370">Can we trust Big Tobacco to promote public health?</a>
</strong>
</em>
</p>
<hr>
<p>Tobacco control is also a great example of how coordinated actions from a number of different government sectors can be targeted to address a major public health challenge. </p>
<p>Australia has been recognised <a href="https://apps.who.int/iris/bitstream/handle/10665/326043/9789241516204-eng.pdf?ua=1">as a world leader</a> in this area.</p>
<h2>Motor vehicle safety</h2>
<p>Motor vehicles have been a great advancement in modern society, but have also been a major cause of injury and <a href="https://www.abc.net.au/news/2018-01-25/every-road-death-in-australia-since-1989/9353794">death</a>. </p>
<p>Road deaths in industrialised countries have <a href="https://www.who.int/violence_injury_prevention/publications/road_traffic/world_report/chapter2.pdf">declined significantly</a> in the last few decades. This reduction has occurred despite the increased number of drivers and distances travelled on the roads in this period.</p>
<p>We’ve been able to achieve these safety improvements and therefore reductions in deaths with the help of a wide variety of interventions.</p>
<p>For example, increased regulation in motor vehicle design standards, improved roads, seatbelt regulation, speed limits, drink driving deterrents and the education of drivers.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1118771463945904129"}"></div></p>
<p>Despite the gains made, road traffic accidents remain <a href="https://www.who.int/violence_injury_prevention/road_safety_status/2018/en/">a leading cause of death</a> worldwide, and are a particular problem for developing countries. So there’s still much work to be done in this area.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/a-new-approach-to-cut-death-toll-of-young-people-in-road-accidents-25372">A new approach to cut death toll of young people in road accidents </a>
</strong>
</em>
</p>
<hr>
<p>Public health has played a major role in the increased health and longevity we take for granted in the modern world. But it’s perhaps an area we don’t give much thought to.</p>
<p>One of the reasons public health gains may be under-appreciated is that they are marked by the absence of disease, which can often go unrecognised. For example, while it’s clear when a life has been saved by a medical intervention, it’s much less obvious when disease has been prevented.</p><img src="https://counter.theconversation.com/content/128300/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hassan Vally does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Coronavirus has necessitated a global public health response. But what does ‘public health’ actually mean? Three key examples give us an idea of what public health looks like in action.Hassan Vally, Associate Professor, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1233042019-09-12T20:44:11Z2019-09-12T20:44:11ZThe next battles against tobacco must be fought in the world’s major cities<figure><img src="https://images.theconversation.com/files/291825/original/file-20190910-190031-olddso.jpg?ixlib=rb-1.1.0&rect=73%2C16%2C5316%2C3473&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Ho Chi Minh City, Vietnam, is one of many emerging global metropolises that are struggling to protect residents against tobacco.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Global cities like New York and London were among the first to pioneer <a href="https://doi.org/10.2105/AJPH.2004.058164">effective tobacco control policies</a> — like smoke-free workplaces, public cessation services and higher tobacco taxes. </p>
<p>These life-saving policies were so successful that an international treaty called the Framework Convention on Tobacco Control was negotiated in 2003 to promote similar evidence-based policies throughout the world. Until recently, <a href="https://www.who.int/dg/speeches/2008/20081117/en/">many assumed</a> the <a href="https://www.who.int/fctc/signatories_parties/en/">181 countries that ratified the treaty</a> had benefitted from it.</p>
<p>This month we published <a href="https://doi.org/10.1136/bmj.l2287">new research in the <em>British Medical Journal</em></a> showing that a pre-existing decline in global cigarette consumption was not accelerated by this international tobacco control treaty. </p>
<p>Worse yet, our depressing findings show that while people are smoking less in richer countries like the United States and the United Kingdom, tobacco consumption is rising by over 500 cigarettes per adult in poorer countries like China, Indonesia and Vietnam.</p>
<p>These unexpected results raise two important questions: what could explain these global disparities in tobacco control, and what can be done to address them?</p>
<h2>Tobacco taxes too low</h2>
<p>Global disparities may largely be explained by shifting economic trends and governments’ different capabilities in implementing tobacco control policies. </p>
<p>Rapidly growing metropolises like Beijing, Jakarta and Ho Chi Minh City have not had the same success in protecting their residents against the dangers of tobacco as the richer early-adopting cities.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/291824/original/file-20190910-190044-ex46mr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/291824/original/file-20190910-190044-ex46mr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=337&fit=crop&dpr=1 600w, https://images.theconversation.com/files/291824/original/file-20190910-190044-ex46mr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=337&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/291824/original/file-20190910-190044-ex46mr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=337&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/291824/original/file-20190910-190044-ex46mr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=423&fit=crop&dpr=1 754w, https://images.theconversation.com/files/291824/original/file-20190910-190044-ex46mr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=423&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/291824/original/file-20190910-190044-ex46mr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=423&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Jakarta, Indonesia. Tobacco consumption is rising by by over 500 cigarettes per adult in poorer countries like Indonesia and Vietnam.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>One major reason is that <a href="https://doi.org/10.1007/s00038-017-0955-8">tobacco taxes in these cities are a fraction</a> of what we know they should be and are <a href="https://www.tobaccofreekids.org/assets/global/pdfs/en/Indonesia_tobacco_taxes_report_en.pdf">not rising as quickly as incomes</a>. </p>
<p>As a result, these cities will <a href="http://dx.doi.org/10.1136/tobaccocontrol-2014-051821">lose billions of dollars</a> in lost productivity and health-care expenditures, and the <a href="https://www.who.int/tobacco/publications/surveillance/rep_mortality_attibutable/en/">number one preventable cause of premature death</a> will grow worse every year for hundreds of millions of people.</p>
<h2>Tax avoidance and smuggling</h2>
<p>Yet these emerging cities are not necessarily themselves to blame. Our research, when combined with <a href="https://doi.org/10.1080/17441692.2016.1273370">past studies on the tobacco industry</a>, provides some of the first quantitative evidence for what economists would call an “equilibrium effect” in the tobacco market — whereby the implementation of tobacco control policies in richer countries incentivized tobacco companies to relocate their lobbying, marketing and promotion activities to poorer countries with far less stringent policies.</p>
<p>In fact, there is a tragic irony to this story: the oligopolies dominating the global tobacco market are all headquartered in the very cities that pioneered the tobacco control policies, and these policies now drive industry operations to emerging cities with far fewer protections against this deadly product.</p>
<p>Phillip Morris in New York. British American Tobacco and Imperial Tobacco in London. Japan Tobacco in Tokyo. Not only are these publicly traded companies leveraging capital from wealthy investors in these cities to worsen the tobacco epidemic abroad, they are repatriating billions of dollars back into these wealthy cities through <a href="https://www.theguardian.com/business/2019/apr/30/tobacco-firm-bat-costs-developing-countries-700m-in-tax">systemic tax avoidance</a> and <a href="https://tobaccocontrol.bmj.com/content/tobaccocontrol/13/suppl_2/ii104.full.pdf">international smuggling</a> coordinated at the highest levels — all while <a href="https://doi.org/10.1016/S0140-6736(15)60312-9">aggressively fighting against effective tobacco control policies</a> around the world.</p>
<h2>One billion expected deaths</h2>
<p><a href="https://doi.org/10.1136/bmj.l2287">Our research</a> demonstrates that the Framework Convention on Tobacco Control has not yet led to equitable protection against the harms of tobacco for the great cities of the world. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/291826/original/file-20190910-190026-72f4sm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/291826/original/file-20190910-190026-72f4sm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/291826/original/file-20190910-190026-72f4sm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/291826/original/file-20190910-190026-72f4sm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/291826/original/file-20190910-190026-72f4sm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/291826/original/file-20190910-190026-72f4sm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/291826/original/file-20190910-190026-72f4sm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Tobacco taxes in cities like Beijing are not rising as fast as incomes.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>By 2044 there will be <a href="https://ourworldindata.org/urbanization">twice as many people living in the world’s cities</a> as in rural areas, meaning we cannot leave any city behind if we have any hope of defeating the global tobacco epidemic.</p>
<p>The next stage of this long war must be fought city by city. Whether that means raising tobacco taxes in Beijing, curtailing industry marketing in Jakarta, requiring plain tobacco packaging in Ho Chi Minh City or taking legal action in New York and London — we all have a role to play in fighting <a href="https://www.who.int/tobacco/mpower/2008/en/">to prevent the one billion deaths</a> that are expected from tobacco in the 21st century.</p>
<p>[ <em><a href="https://theconversation.com/ca/newsletters?utm_source=TCCA&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=expertise">Expertise in your inbox. Sign up for The Conversation’s newsletter and get a digest of academic takes on today’s news, every day.</a></em> ]</p><img src="https://counter.theconversation.com/content/123304/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Steven Hoffman declares support from the Canadian Institutes of Health Research (project 312902) and the Research Council of Norway. He was previously employed by WHO.</span></em></p><p class="fine-print"><em><span>Mathieu JP Poirier does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Rapidly growing metropolises like Beijing, Jakarta and Ho Chi Minh City are struggling to protect residents against tobacco. Life-saving policies in rich countries may be partially to blame.Steven J. Hoffman, Director, Global Strategy Lab and Professor of Global Health, Law, and Political Science, York University, CanadaMathieu JP Poirier, Assistant Professor of Soclal Epidemiology, York University, CanadaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1168192019-05-31T07:33:29Z2019-05-31T07:33:29ZHow to make anti-smoking campaigns more persuasive<figure><img src="https://images.theconversation.com/files/277332/original/file-20190531-69067-ijg1hd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Cigarettes destroy family health.
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/paper-cut-family-destroyed-by-cigarettes-1400707724?src=kdJ0CEX-7dXB25XxYGXdzQ-1-13">Lion Day/Shutterstock</a></span></figcaption></figure><p>The damaging effects of smoking on our health are well known, and governments are curbing tobacco advertising to reduce the number of smokers. But, in Indonesia, the number of teens and adults who smoke continue to grow at a rate higher than <a href="http://www.wpro.who.int/mediacentre/releases/2018/who_tobacco_trends.pdf">any other country</a>.</p>
<p>A World Health Organisation (WHO) survey of nearly 6,000 respondents found almost <a href="http://www.searo.who.int/tobacco/data/ino_gyts_fs_2014.pdf">60% of Indonesian teenagers (aged 13-15)</a> are regularly exposed to secondhand smoke at home, and that only <a href="https://www.who.int/tobacco/surveillance/survey/gats/indonesia_factsheet_8_february_2012.pdf?ua=1">24.5%</a> of adult smokers believed smoking tobacco could cause serious illness.</p>
<p>To increase public awareness of the harmful and deadly effects of tobacco use and secondhand smoke exposure, and to discourage the use of tobacco in any form, the WHO and global partners <a href="https://www.who.int/news-room/events/detail/2019/05/31/default-calendar/world-no-tobacco-day">celebrate World No Tobacco Day (WNTD) every year on 31 May</a>. </p>
<p>Indonesia’s Health Ministry has carried out anti-smoking campaigns to reduce smoking; the latest was launched in 2018. But the campaign messages <a href="http://jurnalaspikom.org/index.php/aspikom/article/view/140">are not persuasive enough</a>. </p>
<p>I argue that designing anti-smoking campaign messages based on tried and tested health communication theories will make the messages more powerful. </p>
<h2>Problem of anti-smoking campaigns</h2>
<p>Anti-smoking campaigns in Indonesia are presented as public service announcements on national television and digital media. The Health Ministry launched the latest anti-smoking social media campaign with the hashtag <a href="http://suaratanparokok.co.id/">#SuaraTanpaRokok</a>, which translates as voices without cigarettes. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/OSZDvsCcn9o?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Ranap Simatupang and other victims’ stories in #SuaraTanpaRokok (Voices without Cigarettes).</span></figcaption>
</figure>
<p>From my observation of <a href="http://suaratanparokok.co.id">#SuaraTanpaRokok</a>, the campaign only focused on attitudes of fear and sadness to indicate disapproval of smoking and perceived risk of smoking. </p>
<p>The campaign tells stories of people who had cancer due to smoking, such as <a href="https://www.facebook.com/suaratanparokok/photos/rpp.912556722136592/2434548039937445/?type=3&theater">Zainal Arifin Nasution</a>, who underwent surgery for laryngeal cancer, and <a href="http://suaratanparokok.co.id/">Ranap Simatupang</a>, who died from lung cancer. The campaign also shows the risk of smoking through <a href="https://twitter.com/SuaraTanpaRokok/status/1055776308108713984">images</a> of lung disease.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1055776308108713984"}"></div></p>
<h2>Persuasive campaign: reasoned action</h2>
<p>We need a variety of approaches to designing health messages. Aside from the type of health campaigns the government currently uses, which highlight fear and sadness due to risks of smoking, several social influence theories can be used to develop compelling messages.</p>
<p><a href="https://doi.org/10.1097/00124784-200006030-00013">Health communication research</a> has demonstrated that health messages that challenge people’s perception of social norms are effective in changing behaviour and in building people’s confidence to stop smoking. </p>
<p>Health campaigns on <a href="https://www.ncbi.nlm.nih.gov/pubmed/9615241">cancer, anti-smoking</a> and HIV/AIDS awareness often use the theory of reasoned action developed by <a href="http://people.umass.edu/aizen/f&a1975.html">Fishbein and Ajzen (1975)</a>. </p>
<p>This theory assumes that a person who wants and intends to avoid getting sick will carry out preventive health care. A person’s intention is influenced by their attitude towards behaviours relating to preventive health care as well as by how others view those behaviours. </p>
<p>Based on this theory, persuading someone by targeting their attitudes and social norms can change their behaviours. </p>
<p>Take anti-smoking advertisements in the US, for instance, where campaigns often provide reasoned arguments or messages focusing on what other people think about smoking (social norms) or on individual attitudes toward smoking (personal attitudes). </p>
<p>In “<a href="https://www.youtube.com/watch?v=kdz0aH3rElY">Addicted Ashtray</a>”, a girl who is addicted to smoking finds the cigarette vending machine is out of order. She then takes a half-smoked cigarette from an ashtray. This type of health message aims to show that smoking leads to disgusting behaviour. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/kdz0aH3rElY?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">“Addicted Ashtray”, a South Dakota Department of Health TV ad that asks smokers to rethink the role tobacco plays in their life.</span></figcaption>
</figure>
<p>This approach challenges someone’s attitude towards smoking because they would not want to associate themselves with the appalling behaviour presented in the campaign. This could also make smokers think about how their family and friends view smoking behaviour. </p>
<p>Anti-smoking advertisements can also attempt to influence attitudes by providing information about the toxic content of a cigarette. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/EXdxl0yH904?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">This anti-smoking commercial tells the audience how chemicals in lit cigarettes can cause disastrous health effects.</span></figcaption>
</figure>
<h2>Trying to quit</h2>
<p>Smoking is addictive, so quitting is difficult for those who are hooked. Designing campaign messages based on <a href="https://www.tandfonline.com/doi/abs/10.1080/08870449808407422">social cognitive theory</a> might make people who are struggling to quit feel represented. </p>
<p>Based on this theory, when people see that the message is directed toward their behaviour, the message gains greater representational meaning. So anti-smoking campaigns might provide a story of <a href="https://www.youtube.com/watch?v=6OZehKDHsj0">someone who has quit smoking or is trying to</a>. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/6OZehKDHsj0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Tiffany had a strong, emotional reason to quit smoking: at age 16, she lost her mother to lung cancer.</span></figcaption>
</figure>
<h2>Showing benefits of quitting</h2>
<p>We can also use <a href="https://www.ncbi.nlm.nih.gov/pubmed/3378902">the health belief model (HBM)</a> to design anti-smoking campaigns. </p>
<p>HBM posits that an individual will make behaviour changes by assessing not only the risks of their behaviour but also barriers and benefits.</p>
<p>Anti-smoking campaigns can thus also focus on the benefits of not smoking. For example, the <a href="https://www.cdc.gov/tobacco/campaign/tips/quit-smoking/guide/rewards-of-quitting.html">US Centers for Disease Control and Prevention</a> give a list of health benefits of being smoke-free: you can enjoy a healthy heart, healthy lungs and lower risks of cancer and erectile dysfunction. </p>
<p>Indonesia’s anti-smoking campaign still focuses on the severe harm that smoking causes. Various communication theories exist and using them to design anti-smoking campaigns can lead to a more effective variety of messages targeting new and young smokers.</p><img src="https://counter.theconversation.com/content/116819/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Juhri Selamet tidak bekerja, menjadi konsultan, memiliki saham, atau menerima dana dari perusahaan atau organisasi mana pun yang akan mengambil untung dari artikel ini, dan telah mengungkapkan bahwa ia tidak memiliki afiliasi selain yang telah disebut di atas.</span></em></p>Designing anti-smoking campaign messages based on tried and tested health communication theories will make the messages more powerful.Juhri Selamet, Lecturer, Universitas Multimedia NusantaraLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1086952019-01-08T12:45:33Z2019-01-08T12:45:33ZNigeria isn’t doing enough to reduce tobacco use. Here’s why<figure><img src="https://images.theconversation.com/files/251214/original/file-20181218-27761-ke1zko.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Because of its size, Nigeria has the potential to boost the global anti-tobacco movement.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Tobacco remains the biggest public health threat, killing more than <a href="https://www.who.int/en/news-room/fact-sheets/detail/tobacco">seven million</a> people globally every year. The <a href="https://www.who.int/fctc/reporting/WHO-FCTC-2018_global_progress_report.pdf?ua=1&ua=1">World Health Organisation (WHO)</a> has recognised progress in Nigeria, but concerns remain about effective implementation. </p>
<p>Nigeria is a key tobacco industry market in Africa because of its population size and access to other markets in the region. One of the largest publicly traded tobacco companies in the world, British American Tobacco, built a state-of-the-art manufacturing plant in the country in 2003 to service <a href="http://www.batnigeria.com/group/sites/BAT_7YKM7R.nsf/vwPagesWebLive/DO7YKMMJ?opendocument">West African countries</a>. In 2016, BAT opened its new West Africa Head Office in <a href="https://www.vanguardngr.com/2016/01/batn-office-complex-a-confluence-of-splendour-allure-and-luxury/">Lagos</a>. </p>
<p>A Global Adult Tobacco Survey done six years ago estimated that <a href="https://afro.who.int/news/government-nigeria-releases-first-ever-global-adult-tobacco-survey-gats-report-african-region">4.5 million</a> Nigerian adults smoked. The country has an estimated population of <a href="http://worldpopulationreview.com/countries/nigeria-population/">198 million</a>. Nearly a third of the adult population was exposed to secondhand smoke. </p>
<p>Nigeria started trying to <a href="https://www.ncbi.nlm.nih.gov/pubmed/28199720">regulate tobacco smoking in the 1970s</a>. But it only enacted its first <a href="https://www.tobaccocontrollaws.org/files/live/Nigeria/Nigeria%20-%20Tobacco%20Smoking%20%28Control%29%20-%20national.pdf">tobacco smoking control decree</a> in 1990. This made Nigeria one of the first African countries to regulate tobacco. But the decree became less and less relevant because the government didn’t raise public awareness or prioritise <a href="https://www.ncbi.nlm.nih.gov/pubmed/28199720">implementation</a>.</p>
<p>In 2005, Nigeria signed the <a href="http://www.who.int/fctc/text_download/en/">WHO Framework Convention on Tobacco Control</a>. But it took until 2015 to pass a law, the <a href="https://www.tobaccocontrollaws.org/files/live/Nigeria/Nigeria%20-%20TCA%20-%20national.pdf">National Tobacco Control Act</a> to implement the framework.</p>
<p>Nigeria’s 2015 National Tobacco Control Act was an <a href="https://www.ncbi.nlm.nih.gov/pubmed/29660032">improvement on the 1990 Act</a> because, among other things, it:</p>
<ul>
<li><p>regulated the interaction of government and industry, </p></li>
<li><p>regulated e-cigarettes, and other tobacco products, </p></li>
<li><p>established the National Tobacco Control Committee (a multisectorial coordinating mechanism) and a Tobacco Control Fund, and </p></li>
<li><p>stipulated more stringent measures for violating the law. </p></li>
</ul>
<p>But the law had lots of <a href="https://www.ncbi.nlm.nih.gov/pubmed/29660032">loopholes</a>. And three years later it still hasn’t been implemented. </p>
<h2>Why implementation is moving so slowly</h2>
<p>The non-implementation of the 2015 tobacco law is due to <a href="https://www.ncbi.nlm.nih.gov/pubmed/29660032">problematic clauses</a> slipped in late in the process of passing it.</p>
<p>In particular, the act includes the unprecedented requirement that regulations prepared by the federal ministry of health must be approved by the National Assembly. This additional step slows down the process. It also provides another opportunity for the tobacco industry to block progress.</p>
<p>The regulations have not yet been submitted to the National Assembly.</p>
<p>The law also requires the Standards Organisation of Nigeria, a body that regulates products, to issue guidelines for regulating tobacco products. </p>
<p>A major problem with the organisation is that the tobacco industry dominates its processes. For example, tobacco industry representatives outnumber those from other agencies on the committee that writes the guidelines. </p>
<p>The Standards Organisation has defended this situation by saying it is mandated by law to include the industry. But having the tobacco industry on the committee is a serious impediment to developing effective regulations. </p>
<p>Another problem with these guidelines is that they only cover cigarettes at present, not all tobacco products. This leaves snuff, hookah, pipe, and e-cigarettes without any regulatory guidelines.</p>
<p>The tobacco industry in Nigeria is <a href="https://www.ncbi.nlm.nih.gov/pubmed/22370696">aware of every move</a> the government makes even before new measures are introduced. This is because it has representatives on the regulatory committee as well as through membership of the National Tobacco Control Committee. This means that the industry is in a position to mobilise against any new regulations. </p>
<p>These situations represent clear conflicts of interest and violate Article 5.3 of the WHO’s <a href="http://www.who.int/fctc/guidelines/article_5_3.pdf">framework</a> which commits parties to insulate public health policy making process from the tobacco industry’s interference.</p>
<h2>Moving Forward</h2>
<p>Fresh efforts have been made to close the loopholes in the 2015 law by getting an updated law <a href="https://nass.gov.ng/document/download/10059">through the Senate</a>. This includes ensuring that there is zero industry interference</p>
<p>Because of its size, Nigeria has the potential to boost the global anti-tobacco movement. But this requires it to have comprehensive laws in place that are compliant with the Framework Convention on Tobacco Control. And that are properly implemented and evaluated. </p>
<p>Advocates and policymakers in other African and low and middle income countries should <a href="https://www.ncbi.nlm.nih.gov/pubmed/30045974">learn from Nigeria’s experience</a> and focus on making laws that are strong from the outset. </p>
<p>And since the tobacco industry is a major threat to comprehensive and effective tobacco control policies, countries should ensure strict compliance with the framework to ensure non-interference – direct or indirect.</p>
<p>The other step the Nigerian government needs to address is the fact that tobacco control is massively underfunded. Tobacco control is mostly funded by international donor agencies rather than the government. It’s time the government took responsibility for the lives of its people and adequately fund tobacco control activities.</p><img src="https://counter.theconversation.com/content/108695/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine O. Egbe, PhD currently works for the South African Medical Research Council, Alcohol, Tobacco and Other Drug Research Unit, Pretoria, South Africa. </span></em></p><p class="fine-print"><em><span>Stanton Glantz receives funding from the National Institutes of Health and the Truth Initiative.</span></em></p><p class="fine-print"><em><span>Stella A. Bialous receives funding from research funding from California’s Tobacco Related Diseases Research Program, NCI, ISNCC. She is a board member of Americans for Nonsmokers Rights, international Society of nurses in cancer Care, sacred heart cathedral preparatory.</span></em></p>The National Tobacco Control Act gives the tobacco industry inside access to the decision making process.Catherine O. Egbe, PhD, Specialist Scientist, Alcohol Tobacco and Other Drug Research Unit, South African Medical Research CouncilStanton Glantz, Professor of Medicine, University of California, San FranciscoStella A. Bialous, Associate Professor, School of Nursing and Center for Tobacco Control Research and Education, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1079982018-12-21T11:41:15Z2018-12-21T11:41:15ZFlavored e-cigarettes are fueling a dangerous increase in vaping use<figure><img src="https://images.theconversation.com/files/251603/original/file-20181219-45391-158rcdq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Studies have suggested that teens' perception of risk in these products is influenced by flavor.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/health-problems-social-issues-teenagers-smoking-441252415?src=UNWOaWnEmJbYlrHYnqeD5Q-1-0">Diego Cervo/Shutterstock.com</a></span></figcaption></figure><p>An upsurge in e-cigarette use among middle and high school students occurred nationally between 2011 and 2018, with nearly 21 of every 100 high school students surveyed reporting e-cigarette use in the past 30 days, according to <a href="https://www.cdc.gov/mmwr/volumes/67/wr/mm6745a5.htm?s_cid=mm6745a5_w#contribAff">data from experts</a> at the U.S. Food and Drug Administration and the Centers for Disease Control and Prevention.</p>
<p>This trend is not by chance. Tobacco companies have spent billions of dollars annually on tobacco product advertisement, <a href="https://www.ftc.gov/system/files/documents/reports/federal-trade-commission-cigarette-report-2016-federal-trade-commission-smokeless-tobacco-report/ftc_cigarette_report_for_2016_0.pdf">according to a Federal Trade Commission</a> report, and have used appealing packaging, culturally tailored brand names and advertisements <a href="https://www.sciencedirect.com/science/article/pii/S003335061830283X?via%3Dihub">that appear to target specific minorities and youth</a>. The colorful packaging and other strategies employed by the industry contribute to lower harm perceptions of these products and higher susceptibility to use among young people, according to <a href="https://tobaccocontrol.bmj.com/content/24/e4/e233.long">researchers at the Center for Global Tobacco Control</a>, Harvard School of Public Health and <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0196236">recent research on cigarillo packaging I conducted with my research team</a>.</p>
<p>The FDA <a href="https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm620185.htm">has announced</a> efforts to impose restrictions on flavored e-cigarettes and tobacco products. FDA recognizes the high rates of e-cigarette use among young people as a public health concern, and sees the urgent need for stricter product access.</p>
<p>Part of the agency’s plans call for restricting young people under the age of 18 from accessing flavored e-cigarettes via retail establishments and online websites. The FDA is seeking to have retailers move flavored e-cigarette products – excluding mint- and menthol-flavored products – to age-restricted areas in stores, and the FDA is proposing to heighten practices for age verification online. Agency officials have also called for removing e-cigarette products that are marketed to kids, <a href="https://www.nytimes.com/2018/11/15/health/ecigarettes-fda-flavors-ban.html">among other measures</a>.</p>
<p>And with the announcement that tobacco giant Altria paid US$13 billion for a <a href="https://www.wsj.com/articles/altria-takes-35-stake-in-e-cigarette-maker-juul-11545309399">35 percent stake in Juul</a>, the vaping company that uses flavors to market its e-cigarettes, the need to impose youth restrictions on flavored tobacco products takes on even more urgency.</p>
<h2>Flavors change perception of risk</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/251628/original/file-20181219-45391-1hjk2u8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/251628/original/file-20181219-45391-1hjk2u8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/251628/original/file-20181219-45391-1hjk2u8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/251628/original/file-20181219-45391-1hjk2u8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/251628/original/file-20181219-45391-1hjk2u8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/251628/original/file-20181219-45391-1hjk2u8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/251628/original/file-20181219-45391-1hjk2u8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Studies have suggested that flavoring tobacco and other smoking products leads to a perception that they are not as dangerous.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-female-lighting-cigarillo-matches-woman-1186123162?src=vNx0pcH1Y4Fe-L33Ma9Pww-1-8">Bartlomiej Magierowski/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Using a survey of young adults aged 18 to 26 recruited through an online crowd-sourcing tool, our group of researchers at the University of North Carolina School of Medicine found in a study <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0196236">published in PLOS ONE</a> that cigarillo pack flavor descriptors, such as grape and sweet, and colors such as pink and purple resulted in more favorable product perceptions among young adults. These pack attributes had a greater impact on how people who had never used cigarillos perceived product flavor and taste, compared to current cigarillo users, and people who have previously used them.</p>
<p>Further, we conducted a systematic review of all the scientific literature through April 2016 examining the impact of flavors on tobacco product perceptions and use behaviors. Important findings from this study, published in <a href="https://tobaccocontrol.bmj.com/content/26/6/709">Tobacco Control,</a> suggested that flavored tobacco products have a strong appeal to youth and young adults because of the variety and availability of flavors; that flavors are a reason for use; and that flavors play a primary role in the use of e-cigarettes, little cigars and cigarillos, and hookah among younger people. </p>
<p>Two studies within our <a href="https://www.ncbi.nlm.nih.gov/pubmed/26650455">systematic review</a> found that packs containing flavor descriptions were more likely to be rated as having a lower health risk. Another <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3942180/">study</a> of smokeless tobacco packs in the United States found that young adults were more likely than older adults to report that packs without flavor descriptions would contain more dangerous chemicals. Research is clear that flavored tobacco products have the potential to undermine progress gained to reduce youth tobacco use in the United States.</p>
<h2>Importance of flavors in product use</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/251806/original/file-20181220-103657-1gj4nli.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/251806/original/file-20181220-103657-1gj4nli.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=417&fit=crop&dpr=1 600w, https://images.theconversation.com/files/251806/original/file-20181220-103657-1gj4nli.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=417&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/251806/original/file-20181220-103657-1gj4nli.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=417&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/251806/original/file-20181220-103657-1gj4nli.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=524&fit=crop&dpr=1 754w, https://images.theconversation.com/files/251806/original/file-20181220-103657-1gj4nli.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=524&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/251806/original/file-20181220-103657-1gj4nli.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=524&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The smoking habits of young people are changing, with fewer using traditional cigarettes but more using vaping products.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Teens-Vaping/c6afb61d77af48fa8878b19c7585d33c/2/0">Steven Senne/AP Photo</a></span>
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<p>Research and survey data have shown that tobacco habits in this age group are changing. Youth cigarette smoking rates have declined substantially in recent years, with the <a href="https://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm">National Youth Tobacco Survey</a> showing current use of cigarettes declining from 15.8 percent in 2011 to 7.6 percent in 2017 among high school students, <a href="https://www.cdc.gov/mmwr/volumes/67/wr/mm6722a3.htm">according to data from experts at the CDC and FDA</a>. Meanwhile, e-cigarettes were the most commonly used product in that population in both middle and high school students in the survey data. </p>
<p>While traditional cigarette smoking has declined, patterns of dual (that is, use of two or more tobacco products in 30 days) and poly tobacco use (or the use of three or more tobacco products in 30 days) have emerged. In 2013, in a survey of North Carolina high school students, almost 30 percent reported use of any tobacco product, according to a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4661661/">study</a> from our team published in 2015 in the International Journal of Environmental Research and Public Health. </p>
<p>Within this sample, 19.1 percent used multiple tobacco products, compared with just 10.6 percent of the sample who were single product tobacco users. Youth predominately used cigarettes in combination with little cigars and cigarillos, or cigarettes with e-cigarettes. While there is substantial racial variation in multiple tobacco use patterns over time, in 2015, e-cigarettes were the most commonly used tobacco product among single product users across all racial groups, <a href="https://doi.org/10.1093/ntr/nty051">according to one of our studies published in Nicotine Tobacco Research</a>.</p>
<p>Using data from the 2015 <a href="https://www.tobaccopreventionandcontrol.ncdhhs.gov/data/yts/index.htm">North Carolina Youth Tobacco Survey</a>, we found in a study published earlier this year in <a href="https://www.cdc.gov/pcd/issues/2018/17_0368.htm">Preventing Chronic Disease</a> that among survey respondents who were not susceptible to smoking cigarettes, 26 percent were at “high risk” for future e-cigarette use; 11.3 percent were classified as “susceptible” to using e-cigarettes; 10.4 percent had already tried an e-cigarette; and 4.5 percent were current e-cigarette users. </p>
<p>Using school enrollment figures, we estimated that 55,725 high school students in our home state of North Carolina were at low-risk of smoking cigarettes, but at high risk for e-cigarette use – which meant that they were susceptible to using e-cigarettes, had experimented with e-cigarettes, or currently used e-cigarettes. On a national scale, these findings are a considerable public health problem.</p>
<p>Specifically, high school students who believed that e-cigarettes and secondhand e-cigarette vapor were not harmful, or only somewhat harmful, were more likely to be susceptible to using e-cigarettes than students who thought e-cigarettes and secondhand e-cigarette vapor were harmful, <a href="https://www.cdc.gov/pcd/issues/2018/17_0368.htm">our study found</a>. </p>
<p>Moreover, exposure to e-cigarette vapor in indoor or outdoor public places was associated with greater odds of being susceptible to using e-cigarettes. This could mean that restricting secondhand exposure to vapor of e-cigarettes in public places, such as in school buildings, stores, restaurants, school grounds and parks, and mass media efforts to educate youth about the harms of e-cigarette use could be just as necessary as restricting access to these products.</p>
<p><a href="https://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/factsheet.html">We know</a> that adolescents and teenagers are very vulnerable to the influence of tobacco marketing. The use of appealing packages and flavors has a significant impact on young people, causing them to perceive these tobacco products as less harmful and, in turn, making them more likely to experiment and continue using tobacco products. As research on the impact of flavored tobacco products builds, I look forward to increased action to help prevent youth tobacco use.</p><img src="https://counter.theconversation.com/content/107998/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Leah Ranney receives funding from NIH/FDA. I was part of the UNC Tobacco Centers of Regulatory Science award.</span></em></p>E-cigarette usage among teens has surged. A tobacco control expert explains how flavors may be contributing.Leah Ranney, Director of Tobacco Prevention and Evaluation, University of North Carolina at Chapel HillLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1009662018-08-14T20:26:44Z2018-08-14T20:26:44ZWhy Australian prisoners are smoking nicotine-infused tea leaves<figure><img src="https://images.theconversation.com/files/231807/original/file-20180813-2900-1igpw2p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Prison represents only a temporary disruption in tobacco use for many smokers.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1119711299?src=StGCHrvIZoRW7ATFs2QQSw-1-18&size=huge_jpg">TeodorLazarev</a></span></figcaption></figure><p>Following a ban on tobacco smoking in prisons, some Australian prisoners are creating substitute cigarettes from crushed nicotine lozenges mixed with tea leaves. More than half of the participants we sampled in our <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/dar.12848">recent study</a> have used this product, known as “teabacco”.</p>
<p>Around <a href="https://www.aihw.gov.au/reports/prisoners/health-of-australias-prisoners-2015/contents/smoking">74% of prisoners entering the system</a> are smokers. This is partly because groups who smoke at higher rates in the community – such as people who <a href="http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4364.0.55.001%7E2014-15%7EMain%20Features%7ESmoking%7E24">are poor and disadvantaged</a>, identify as <a href="https://www.mja.com.au/journal/2015/202/10/talking-about-smokes-large-scale-community-based-participatory-research-project">Indigenous</a>, or experience <a href="https://www.ncbi.nlm.nih.gov/pubmed/16492581">mental health or substance use disorders</a> – are all <a href="https://www.aihw.gov.au/reports/prisoners/health-of-australias-prisoners-2015/contents/table-of-contents">overrepresented</a> in prisons.</p>
<p>But despite not having access to regular cigarettes while incarcerated, <a href="https://www.ncbi.nlm.nih.gov/pubmed/29660697">most former prisoners</a> (94%) resume the habit on release, and many will go on to develop <a href="https://www.nejm.org/doi/full/10.1056/NEJMsa064115">smoking-related illnesses</a>. In other words, prison represents only a temporary disruption in tobacco use for many smokers, and many are still smoking, albeit a different substance.</p>
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Read more:
<a href="https://theconversation.com/breaking-bad-habits-classical-conditioning-and-smoking-11578">Breaking bad habits: classical conditioning and smoking</a>
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<p>Simply providing nicotine lozenges isn’t enough to change the entrenched behaviour of long-term smokers. We need to provide better support for Australians in prison to quit smoking and improve their long-term health. They deserve the same quitting services as those in the community.</p>
<h2>When was smoking banned?</h2>
<p>Smoking has been banned in all prisons in Queensland, the Northern Territory, Tasmania, Victoria, and New South Wales <a href="https://www.mja.com.au/journal/2015/203/8/smoking-bans-prison-time-breather">since 2015</a>. While <a href="http://www.corrections.sa.gov.au/about/our-research/smokefree-prisons-strategy">South Australia</a> is due to follow in 2019, smoking is still permitted in prison cells in Western Australia and the Australian Capital Territory.</p>
<p>Smoking bans have been well received by most Australian prisoners, with <a href="https://www.ncbi.nlm.nih.gov/pubmed/29660697">most</a> saying they want to stay off cigarettes. Only one documented riot (at <a href="https://theconversation.com/why-banning-smoking-in-prisons-is-a-good-idea-44139">the Melbourne’s Metropolitan Remand Centre</a>*) has coincided with a smoking ban in Australia, and an <a href="http://assets.justice.vic.gov.au/corrections/resources/198d00c1-c2ad-4089-98c6-bffc074880c3/mrc_riot_final_report.pdf">independent evaluation</a> determined that overcrowding and inadequate fencing were also contributing factors.</p>
<p>However, besides making nicotine lozenges available for purchase (and patches before that), Australian prison or health authorities have not implemented any formal program to help people in prison to quit smoking, or to stay off cigarettes when they are released.</p>
<h2>How teabacco is used</h2>
<p><a href="https://onlinelibrary.wiley.com/doi/full/10.1111/dar.12848">To make teabacco</a>, prisoners first crush nicotine lozenges, which are available for sale from most prison shops. They then mix the crushed lozenges with rinsed tea leaves. This blend is then wrapped in Bible paper, which is easily obtained from prison-based ministry services.</p>
<p>To get a sense of how widespread this practice is, we <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/dar.12848">surveyed 82 former smokers recently released from Queensland prisons</a> about their teabacco use. More than half (57%) said they had tried teabacco while in prison. One-third (37%) had used it more than once a week, mainly to alleviate cravings for cigarettes. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/231838/original/file-20180814-2921-12r14cw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/231838/original/file-20180814-2921-12r14cw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/231838/original/file-20180814-2921-12r14cw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/231838/original/file-20180814-2921-12r14cw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/231838/original/file-20180814-2921-12r14cw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/231838/original/file-20180814-2921-12r14cw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/231838/original/file-20180814-2921-12r14cw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Prisoners should have access to the same subsidised medications to quit smoking as the rest of the population.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1154216977?src=_hnUQp0HjD1IgI21o4lB4A-1-2&size=huge_jpg">Shutterstock</a></span>
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<p>Previously, prisoners in Queensland were making teabacco from nicotine patches, which were provided for free when the smoking ban was implemented. But after <a href="https://www.ncbi.nlm.nih.gov/pubmed/26094737">researchers found</a> that smoking nicotine patches releases potentially harmful toxins, the patches were removed from all prisons. </p>
<p>Participants in <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/dar.12848">our study</a> described how prisoners then switched to making teabacco from nicotine lozenges instead.</p>
<h2>Should lozenges be banned?</h2>
<p>No, removing nicotine lozenges from prisons isn’t the answer. </p>
<p>Our forensic analysis of the chemical compounds of teabacco made from nicotine lozenges, published today in the journal <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/dta.2471">Drug Testing and Analysis</a>, reveals only small amounts of most potentially harmful compounds. This means that teabacco made from lozenges is actually <em>less</em> harmful to smoke than commercial cigarettes. </p>
<p>In light of these findings, and considering that nicotine lozenges are the only quit tool available in most prisons, we caution against removing nicotine lozenges from prisons – at least until further research can clearly determine the potential harms. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/why-banning-smoking-in-prisons-is-a-good-idea-44139">Why banning smoking in prisons is a good idea</a>
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<p>A few participants in <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/dar.12848">our study</a> also reported smoking plain tea leaves when nicotine lozenges were not available, suggesting a degree of inevitability in some prisoners finding something to smoke. </p>
<p>Prison-based awareness campaigns may help to alert prisoners to the fact that more nicotine can be absorbed from sucking lozenges, as outlined on the dosage instructions.</p>
<h2>How to improve prisoners’ health</h2>
<p>Helping prisoners to quit smoking has both health and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5801657/">financial</a> benefits, both for individuals and <a href="https://www.ncbi.nlm.nih.gov/pubmed/24922122">at the population level</a>, by reducing the burden on the health system. </p>
<p>While most Australians can access cheaper medications to help quit smoking through the Pharmaceutical Benefits Scheme, <a href="https://www.doctorportal.com.au/mjainsight/2017/27/call-to-include-prisoners-in-medicare-and-pbs/">prisoners are excluded</a> from this scheme. This is in violation of <a href="https://www.unodc.org/documents/justice-and-prison-reform/GA-RESOLUTION/E_ebook.pdf">United Nations’ “Mandela Rule” 24.1</a>, which requires health services in prison to be equivalent to those available in the community. </p>
<p>Prisoners would also benefit from access to other forms of quit smoking support, such as <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1675874">behavioural counselling</a> or <a href="https://www.bmj.com/content/360/bmj.j5543">e-cigarettes</a>. These options help people to cope with symptoms of nicotine withdrawal and other behavioural triggers that cause smoking relapse. </p>
<p>If we’re serious about helping prisoners quit smoking tobacco – or teabacco – we need to offer evidence-based options to help prisoners quit smoking for good. </p>
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Read more:
<a href="https://theconversation.com/three-charts-on-australias-booming-prison-population-76940">Three charts on: Australia's booming prison population</a>
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<p><em>* This article originally said the riot was at Ravenhall Prison, rather than the Metropolitan Remand Centre.</em></p><img src="https://counter.theconversation.com/content/100966/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jason Ferris is the chief data scientist for the Global Drug Survey, founded by Adam Winstock. He has received funding from National Health and Medical Research Council, The Australian Research Council, the Foundation for Alcohol Research and Education, Queensland Government, Australian & New Zealand Association of Oral & Maxillofacial Surgeons, Tasmanian Department of Health and Human Services, Criminology Research Grant, Victorian Law Enforcement Drug Fund, Department of Health and Ageing, VicHealth, Australian National Preventive Health Agency</span></em></p><p class="fine-print"><em><span>Stuart Kinner receives funding from the National Health and Medical Research Council, and the Victorian Health Promotion Foundation.</span></em></p><p class="fine-print"><em><span>Cheneal Puljević and Ross Coomber do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The only quitting tool most Australian prisoners have access to is nicotine lozenges. These are being mixed with tea leaves to create a smokable product known as “teabacco”.Cheneal Puljević, Research Fellow, Centre for Health Services Research, The University of QueenslandJason Ferris, Associate Professor, Senior Biostatistician and Program Leader, The University of QueenslandRoss Coomber, Professor of Criminology and Sociology, University of LiverpoolStuart Kinner, Professor, Murdoch Children's Research InstituteLicensed as Creative Commons – attribution, no derivatives.