NEWS
Waiting for the domino effect
This month, landmark legislation comes into force in Australia, making it the first country to ban branded cigarette packaging. Mike Daube talks to Fiona Fleck about how public health campaigning has come a long way since the 1970s.
Q: When did you start campaigning for tobacco control, and why?
A: I started working on tobacco in the United Kingdom of Great Britain and Northern Ireland in early 1973, as the first full-time director of Action on Smoking and Health, so - a long time ago. Recently, an American researcher working on the early days of tobacco control phoned and said excitedly, 'I've just discovered that you're still alive!' In those days there was no tobacco control advocacy as we now know it. I saw tobacco as a massive public health problem that was barely being addressed and that needed a different approach. There was overwhelming evidence on the magnitude of the problem and concern in the medical establishment, but very little was actually being done. It was a campaign crying out to be fought.
Q: What was it like campaigning in those days?
A: It's difficult to describe how tough it was. Things were so different. Misconceptions were rife. The media thought that every time someone spoke about the dangers of smoking, "balance" required someone from the industry to deny the evidence. A leading health reporter told me in 1973, "you're never going to find anything new to say about smoking". The tobacco companies were powerful and respectable: their leaders got knighthoods and peerages. Respected medical researchers worked with and took funding from tobacco companies. The Royal College of Physicians invited comments and amendments on its reports from the tobacco industry, until I got them to stop. At my first ASH meeting in the Royal College of Physicians in 1973 some of the country's most distinguished doctors, frustrated by the lack of progress, debated for two hours what they could do to make the government quake in its boots. Eventually they had the answer: they would write a letter to the Lancet.
Q: Why was there so little understanding of tobacco control?
A: Most people didn't understand the magnitude of the problem and just how ruthless the industry was and, in those days, we didn't have access to confidential industry documents now available following the US Master Settlement Agreement. There was no real peer group in the country, and only a few colleagues outside the United Kingdom. There was very little money for campaigning. Once I had to deliver media releases to the newspaper offices around Fleet Street on foot in a thunderstorm! The first time I bought shares in tobacco companies so that we could ask questions at their annual general meetings - such as "How many deaths were the company's products responsible for in the last year?" - I didn't dare to tell the ASH board. But after the first one, they all wanted to join in the fun! I am amazed, in retrospect, at how generous the medical hierarchy was to a young man with long hair and a penchant for purple suits, who wanted to turn ASH into a real pressure group. I was unbelievably privileged to work with some of the great figures in the United Kingdom's public health history: Charles Fletcher, Sir George Godber, Keith Ball, Lord Platt, David Player and Sir John and Eileen Crofton, as well as wonderful international colleagues including Nigel Gray, Kjell Bjartveit, Michael Pertschuk, Stan Glantz and Matt Myers. A real joy of later decades has been working with Simon Chapman, Melanie Wakefield, Maurice Swanson and other terrific colleagues in Australia and elsewhere.
Q: What were the early successes?
A: We got tremendous media and community interest. Some superb journalists in all media made crucial contributions, along with support from journals such as the BMJ. Tobacco companies reacted angrily to our work. Governments responded to the media attention, with action in areas including advertising controls, tax and public education. One year we got eight cigarette brands withdrawn from the market (two, named "Rapier" and "Stiletto", by pointing out how appropriate it was to name them after lethal weapons); the Chancellor of the Exchequer (finance minister) made the case for tobacco tax increases as a health measure; there were further curbs on tobacco promotion; we ended some appalling forms of promotion; and doctors and health professionals got increasingly interested in campaigning. It didn't all happen at once. But in tobacco control, once you get a win, others will follow. When I moved to Western Australia in 1984, I had the privilege there of overseeing the first major, well-funded, long-term media campaign: "Quit". We had a fabulous team and showed that powerful media campaigns, allied with advocacy, can have a dramatic impact. That also helped us to move towards a law banning tobacco advertising in 1991.
Q: Have you personally faced difficulties with the tobacco industry?
A: I have been attacked by tobacco companies for the past 40 years. Tobacco magazine described me in 1973 as "an earnest, dogmatic young man", but it got much worse after that. I have been sued by tobacco companies, followed, warned off by people in the industry and some of their friends in government. I have been undermined by politicians, civil servants and academics, who later worked for the industry, and I have been regularly attacked in the media by tobacco companies and their allies. In the 1970s, the chairman of a major tobacco company offered me funding to work on another campaign - on any issue other than tobacco.
Q: What was the most fraught situation you encountered?
A: In 1983, when I was an academic in the Department of Community Medicine at Edinburgh University, I was selected for appointment to a senior position at the British Government's Health Education Council, to run mass media campaigns on tobacco and other issues. Following industry lobbying, the government overruled the decision of the selection panel. This resulted in a media furore and also, shortly afterwards, the offer of a senior position in Australia, which I accepted. Years later, when the government changed, the former secretary of state joined the board of British American Tobacco, and became their deputy chairman. To say that I felt vindicated would be an understatement!
Q: Are people more aware of such conflicts of interest today?
A: Much more, yes, particularly in developed countries. Most politicians are terrified of being named and shamed for any links with tobacco. But that applies only in some developed countries and even in Australia some political parties still accept tobacco company donations. Around the world there is undoubtedly still enormous conflict of interest and, probably, corruption.
Q: How did the Australian government's plan for plain packaging prevail in spite of major legal challenges from the tobacco industry?
A: The health minister, Nicola Roxon, was determined and unwavering. She was supported by a strong, well-coordinated coalition of health groups, great campaigners and researchers, and excellent work in the health department. The legal case for plain packaging was sound, based on excellent research, and superbly run by the minister and her department. It helped that the tobacco industry in Australia has so little credibility, was so clearly desperate, and lobbied so crassly and that the community and the media were so supportive.
Q: What hurdles did the government overcome?
A: The biggest hurdle was the power and determination of the global tobacco industry. They threw everything they could at it and at the minister: public relations, lobbying, media campaigns, personal slurs, front organizations, phony surveys, commissioned reports, claims that plain packaging would increase crime; attempts to distract bureaucrats through Freedom of Information requests, and much more. Despite this, the bill received all-party support.
Q: How do you rate the importance of Australia's plain packaging victory?
A: This is the most important single victory for tobacco control in many years, particularly because of the global implications. In four decades of tobacco control, I have not seen the tobacco industry oppose any measure so ferociously. Their concern is that once implemented in Australia, other countries will follow. Plain packaging has given a tremendous boost to tobacco control worldwide: it has shown that this powerful and ruthless industry can be defeated.
Q: Plain packaging comes into force on 1 December for the first time anywhere, is there any evidence for the effectiveness of such a measure on smoking patterns?
A: There is compelling research evidence of the importance of packaging for the promotion of smoking and for making cigarettes more attractive to children. This is complemented by the tobacco industry's own once-confidential research and the ferocity with which companies have tried to salvage the last remaining means of promoting their product publicly.
Q: Who will study the effect of plain packaging on smoking patterns in Australia?
A: There will be a comprehensive evaluation. Plain packaging is not a magic bullet and should not be expected to stop everybody smoking overnight, but it is a very significant step in reducing the attractiveness of smoking to children and encouraging adults to quit. Plain packaging is part of Australia's comprehensive approach that already includes taxation, mass media campaigns, bans on tobacco advertising and promotion, protection for non-smokers, research-based packaging and warnings, and cessation support.
Q: What are the challenges ahead for Australia, especially in light of the World Trade Organization case?
A: The industry will continue to fight through international trade processes, but they have already lost heavily in the High Court, the government would not have taken this on without the best legal advice and the companies have absolutely no option but to comply with the law as from 1 December.
Q: Will this set a precedent for other countries?
A: Yes. We have often seen the domino effect in tobacco control, both nationally and internationally. In Australia, as in Canada and the United States of America, when one state takes action on tobacco, others follow. The same applies with tobacco control globally, whether for advertising bans, health warnings or protection for non-smokers. We needed one country to show that plain packaging could be achieved. There has been terrific support from WHO, and several other countries are looking to follow the Australian example. I sometimes get depressed at how much more progress we could have made over the past 40 years, but now I believe that some countries, where smoking was once the norm, may be smoke-free in my lifetime. 