tobacco controlled – what will it take? oceania tobacco control, brisbane october 2011
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Tobacco controlled – what will it take? Oceania Tobacco Control, Brisbane October 2011. Richard Edwards Department of Public Health, University of Otago, Wellington, New Zealand. Acknowledgements. Many, many colleagues who work on tobacco control related research Particular thanks to: - PowerPoint PPT PresentationTRANSCRIPT
Tobacco controlled – what will it take?
Oceania Tobacco Control, Brisbane October 2011
Richard Edwards
Department of Public Health, University of Otago,
Wellington, New Zealand
Acknowledgements Many, many colleagues who work on tobacco control related
research
Particular thanks to:ASPIRE 2025 team+ Julian Crane and Rob McGee
Nick Wilson Anaru WaaTony Blakely
+ Many others
Structure
What do we mean by tobacco controlled?
Achieving the vision• It is possible!• Some challenges• Some thoughts about the how?
Another (even bigger) challenge Conclusions
Endgame as a goal Zero (or very close to) smoking/tobacco use
prevalence/consumption (Finland, NZ Govt) No/minimal supply of tobacco (Bhutan, NZ govt) Zero or close to zero uptake of tobacco (NZ Tupeka Kore
Vision) Zero or close to zero tobacco related mortality and morbidity
(US Department of Health and Human Services)
A society in which tobacco use is fully denormalised A society in which children are fully protected from tobacco
(NZ Tupeka Kore Vision)
NB Equity issues – ‘….for all social and ethnic groups’.
Endgame as a philosophy
Rejection of the status quo:• i.e. gradual decline in use and prevalence and
incremental policy advances Radical solutions to address an
unacceptable situation Aims to achieve endgame goals quickly
= PARADIGM SHIFT
Percentage smoking by ethnicity, 1991-2007 Pe
rcen
t
0
10
20
30
40
50
60
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
Maori Pacific peoples European/Other All
Source: Statistics New Zealand; ACNielsen (NZ) Ltd, reported in Tobacco Trends 2007
Endgame as a philosophy
Rejection of the status quo:• i.e. gradual decline in use and prevalence and
incremental policy advances Radical solutions to address an
unacceptable situation Aims to achieve endgame goals quickly
= PARADIGM SHIFT
Endgame as a process
Having an explicit government intention and plan to achieve close to zero prevalence of tobacco use.
A clearly stated government ‘end’ target date within a maximum of two decades.
Thompson et al. Tobacco Control (in press)
Endgame as a strategy
A deliberate planned strategy of interventions to achieve endgame goals for tobacco use e.g. • Combinations of established (e.g. price, mass media)
and new (e.g. plain packs, supply restrictions) tobacco control interventions
• Over-arching intervention strategies e.g. sinking lid, regulated market model
Structure
What do we mean by tobacco controlled? Achieving the vision
• It is possible!• Some challenges• Some thoughts about the how?
Another (even bigger) challenge Conclusions
Successful endgame solutions
CFCs Leaded petrol Asbestos Infectious disease eradication (smallpox etc)
Population support for the endgame
0
10
20
30
40
50
60
70
All Māori Pacific
% s
up
po
rt
Agree
Disagree
Source: HSC 2008 Health and Lifestyles Survey Thomson et al. N Z Med J. 2010;123(1308):106-111.
Support for an end of tobacco sales within 10 years
Smoker support for the endgame
0 10 20 30 40 50 60 70 80
Regulating tobaccocompanies more tightly
Government doing more totackle the harm done by
smoking
Increasing the tax ontobacco**
Government setting a dateto ban cigarette sales in 10
years time*
% Support
Maori European/Other
Source: Edwards et al NZ Med J 2009
Daring to Dream: vision is compelling
Participants in daring to dream were presented with a vision of a tobacco free future where children were protected from seeing smoking as a normal behaviour, had virtually no access to tobacco and hence minimal risk of becoming smokers and being exposed to tobacco smoke.
“I think the vision is very good because it …, it makes you stop as a parent and a grandparent and think what the hell are we doing for our kids” – Policy official
Edwards et al. BMC Public Health 2011, 11:580
Young smoker responses to Smokefree 2025 goal
“This is awesome…This makes me feel really proud to be a New Zealander”
Hoek, Maubach et al. Unpublished data.
“I reckon it’s pretty cool. I don’t want to be a smoker in fifteen years.”
“.. it would be something that would be amazing, but I don’t know how possible it would be.”
“2025 ….[pause] am I allowed to swear? [laughs] in your fucking dreams.”
“I’ll be really pissed off when they make it smokefree and I can’t buy cigarettes any more. At least for the first two weeks .. but in the long run, I think smoking is something our country can do without.”
Smoking among doctors and nurses (NZ), 1976-2006
Edwards et al NZMJ 2008; 12: 43-51
Some other occupations (NZ)Occupation 2006 Prevalence
(1981 Census)Dieticians 3.1% (21.2%)
Secondary teachers 7.6% (17.2%)
Ministers of religion 2.7% (8.9%)
Mathematicians and statisticians 4.1% (12%)
Dentists 5.1% (18%)
Structure
What do we mean by tobacco controlled? Achieving the vision
• It is possible!• Some challenges• Some thoughts about the how?
Means and ends Another (even bigger) challenge Conclusions
Challenges
The numbers game - need for mass cessation quickly
Continuing disparities in smoking Shifting patterns of smoking uptake New beliefs, behaviours and influences Lack of ‘proof’ for policy and population-
based approaches Tobacco industry
Interplay of cessation and uptake changes
Source: Gartner et al. Tobacco Control 2009; 18: 183-189.
Challenges
Need for mass cessation quickly Continuing disparities in smoking Shifting patterns of smoking uptake New beliefs, behaviours and influences Lack of ‘proof’ for policy and population-
based approaches Tobacco industry
Adult smoking by ethnic group (NZ)
05
1015202530354045
Asian European Pacific Maori
%
Census 2006 NZHS 2006/07
Adult smoking by deprivation (Census 2006 data, Ponniah et al NZ Med J)
0
5
10
15
20
25
30
35
40
1 2 3 4 5 6 7 8 9 10
Decile (NZDep2006)
%
Disparities in smoking by occupation: NZ 2006 census
Doctors 3.6% Hospital orderlies 27.6%
Nurses 14.2% Nurse aides 23.5%
Secondary teachers 7.6%
Teacher aides 19.5%
Kōhanga Reo teachers 41.2%
Challenges
Need for mass cessation quickly Continuing disparities in smoking Shifting patterns of smoking uptake New beliefs, behaviours and influences Lack of ‘proof’ for policy and population-
based approaches Tobacco industry
Regular smoking by Year 10 female students, 1999-2010 (NZ)
Source: ASH NZ. National Year 10 ASH Snapshot Survey, 1999-2010
Prevalence of current/regular smokers (%), by age group: Census 2006 compared with NZTUS 2006
0%
5%
10%
15%
20%
25%
30%
35%
15-19 years 20-24 years 25-29 years 30-39 years 40-49 years 50-59 years 60-64 years 15-64 years
age group
percentage
Census NZTUS
Source: Statistics New Zealand; NZTUS 2006
28
Smoking among young people in 1996 and 2006 census
17.7
48.9
28.5
50.3
27.6
35.6
16.3
36.1
0
10
20
30
40
50
60
Māori Non-Māori Māori Non-Māori
15-19yrs 20-24yrs
% R
egul
ar s
mok
ers
1996
2006
Shifting uptake results in new challenges
Challenges of preventing uptake in young adults• Lack of research on preventive interventions• Dispersed settings and social networks (c.f.
school)• Increased autonomy• New beliefs about smoking and smoking –related
behaviours and determinants• Legality of purchase and use (different ethical and
moral framework to justify interventions)
Challenges
Need for mass cessation quickly Continuing disparities in smoking Shifting patterns of smoking uptake New beliefs, behaviours and influences Lack of ‘proof’ for policy and population-
based approaches Tobacco industry
New smoking beliefs and behaviours – social smokers
‘I smoke but I am not a smoker’: Phantom smokers (Choi et al. J Am Coll Health 2010: 59: 117-125)• survey of 899 US students (17-25 years). 15.6%
identified as smokers but 45% smoked
New smoking beliefs and behaviours – social smokers (2)
Social smokers differentiate themselves from ‘addicted smokers’:
“I’ve never actually had a cigarette when I I’m just by myself … so I don’t see myself as a smoker, but I see myself as a social smoker … they’re almost mutually exclusive.”
Hoek ,J et al (under review, Tobacco Control)
“Well I actually gave up..in October last year. So I haven’t had a smoke for almost [hesitation] ...I’ve had the odd smoke but I haven’t been a fulltime smoker for almost 12 months ...I might have like one a fortnight, or if I’m having a drink and it’s been a stressful day then I’ll have one but..if I um..if I feel I need one I’ll have one, but other than that I don’t (be)cause I’ve beaten the addiction.”
Ferry, B. Draft MPH dissertation.
New smoking influences – late uptake smokers
“Yip and that’s where I started cause my work mate smoked. Oh he was always offering me one so yeah ...Oh it just gradually built up (laughs). Say we’re doing jobs together and he’d offer me a..and I’d say na..oh the first couple of times..and he’d say..he’d keep on offering and I said ‘why not?’ ..and then..yeah” ‘Peter’
“Oh it was quite horrible really when I think back. Um we were all smokers, we all smoked inside....that’s just what we did...it was a student flat, .. it was a horrible house so we just didn’t really care. ..it was easy to get home and sit down to start with and they’re smoking so you’re like ‘Oh well I might as well have one.’ ” ‘Michelle’Ferry, B. Draft MPH dissertation.
New smoking behaviours – the role of alcohol
NZ ITC study:% Hazardous drinking
(AUDIT >=8)All smokers 33.1%18-24yrs smokers 59.0%Māori smokers 42.1%Pacific smokers 52.1%
Wilson et al. In press NZMJ.
All participants in NZHS – 13.1%
New smoking behaviours – the role of alcohol (2)
Social smokers often only smoke when drinking:
“When I’m drunk, I guess … the care factor goes down … goes down to zero … like who cares about smoking?”
“I just don’t have any cravings unless … I’m out having a few drinks and then I do feel like one…”
“… some nights I can smoke 14 or 15 ciggies or a pack while I am drinking, but I can never do that without alcohol”.
Hoek et al (under review, Tobacco Control)
“I can smoke a whole packet in one night drinking and not have to smoke for two or three days afterwards ….. Yeah I think it’s just social smoking … I think heaps of people are like that…” (Māori female)
“ Well there’s smoke and there’s drink … They’re husband and wife aye.“(19 year old Pacific man)
Glover et al. WhyKwit. Auckland University, 2010
New smoking behaviours – the role of alcohol (3)
Drinking undermines quitting:
“That’s the other thing. You quit and then you drink. You’re used to the habit of having a smoke when you drink. Even when you’re not smoking it goes hand in hand….Oh, a smoke when you drink – just to kick in the buzz.”
Pacific Male smoker Glover et al. WhyKwit. Auckland University, 2010
The role of alcohol – experimental evidence
Diary study with 74 smokers – alcohol use predicted smoking and was associated with urges to smoke and getting a ‘rush’ from smoking.
Piasecki et al Psych Add Behav 2008; 22: 230-239.
Expectation of alcohol increased positive effects of smoking (satisfaction, calming, taste) and administration of alcohol increased smoking and reduced nausea from smoking among 19 young adult experimental smokers.
McKee et al. Psychopharmacology 2010; 210: 355-364.
New smoking behaviours – challenges for tobacco control
• Health education and cessation messages may be ignored by social smokers who do not identify as smokers
• Young adults may respond to different smokefree messaging (and media)
• New interventions needed in settings where smoking occurs: college, workplace, bars etc
• Establishing new social norms about unacceptability of offering cigarettes to new smokers and quitters
• Interventions may be undermined by alcohol and co-intervention may be required
Challenges
Need for mass cessation quickly Continuing disparities in smoking Shifting patterns of smoking uptake New behaviours and influences Lack of ‘proof’ for policy and population-
based approaches Tobacco industry
Lack of ‘proof’ for policy and population-based approaches
Where’s the evidence? – frequent argument of tobacco control opponents and policy-makers
Evidence-base is often limited and difficult to ‘prove’ impact of policy interventions
Evidence base – point of sale
Peer-reviewed evidence (2009):• Observational studies, most cross-sectional, ?
generalisable• Experimental studies limited e.g. exposure and
setting, outcome measures, generalisability etc• Self-reports in surveys and qualitative studies –
limited by possible social desirability etc biases• No published evidence from jurisdictions with
PoS bans
Why the lack of evidence?
Lack of priority and funding for evaluation Methodological difficulties e.g.
• Lack of comparison groups• Lack of control over intervention implementation• Confounding interventions and influences• Lack of data to assess prior trends and long-term
outcomes Novel interventions
Challenges
Need for mass cessation quickly Continuing disparities in smoking Shifting patterns of smoking uptake New behaviours and influences Lack of ‘proof’ for policy and population-
based approaches Tobacco industry
Tobacco industry Arguments
• Interventions don’t work (lack of evidence)• Interventions infringe personal liberty (freedom to choose, nanny
state, slippery slope, commercial freedom, legal product etc etc)• Interventions will have disastrous economic and other unintended
effects Tactics
• Legal challenge, PR and advocacy, lobbying, trade agreements, funds for research and ‘science’ etc etc
Continued marketing• Promotion, price, product (modification), place/accessibility,
Introducing HPP
“… the primary health argument has been lost. There is no way any feasible case can be argued in medical terms….The only way that the right to smoke can be defended is to link it up with the freedom of lifestyle position and with the broader libertarian critique of “health fascism” and the paternalism and authoritarianism of the medical establishment… We have to shift the focus of the debate from the enemy’s strong ground – health – to our strong ground – freedom of choice and individual liberty.”
From Forest’s future strategy: A discussion. Chris Tame, 1989.
Framing the discourse: portray tobacco control advocates and policies as authoritarian
Introducing HPP
Framing: association of smoking with female emancipation
Link tobacco products with cataclysmic and iconic events: Fall of the Berlin wall
“Test the West”
A boy with a West-West shirt on distributes packs of cigarettes to a East German motorcyclist at the West German checkpoint Helmstedt, Nov. 10, 1989.
Structure
What do we mean by tobacco controlled? Achieving the vision
• It is possible!• Some challenges• Some thoughts about the how?
Means and ends Another (even bigger) challenge Conclusions
Some thoughts about the how?
Population vs individual cessation approaches Which methods? Some building blocks for success
Non-smokers Smokers Quit
attemptsInitial
success
Assisted
Unassisted
Long term success
Individual cessation approaches Relapse
Non-smokers Smokers Quit
attemptsInitial
success
Assisted
Unassisted
RelapsePopulation-based approaches
PriceMass mediaMarketing controlsProduct modificationCessation availabilityAccessibilitySmokefree policies
Population approaches vs individual cessation
Modelling study of impact on US smoking prevalence (2020):Current 19.8%Doubling quit attempts 13.9%Doubling treatment effectiveness 15.9%Doubling treatment use 16.7%
Levy et al. AJPH 2010, 100: 1253-1259.
Impacts on population quit rates in New Zealand
Population quit rate (%)
% increase in quit rate
Baseline 1.95 0Quit attempt rate 2.15 10Proportion assisted 1.99 1.8Assisted RR 2.02 3.6Unassisted success 2.15 10Relapse 2.13 9.2
Impact of 10% relative change in each parameterFormula from : Tobias et al. AJPH 100: 1274-1281.
Some thoughts about the how?
Population vs individual cessation approaches Which methods? Some building blocks for success
What methods?
Price/tax increase (duty free) Mass media (campaigns, GHWs etc) Cessation support (treatments, availability etc) Tobacco marketing controls (plain packs, PoS etc) Smokefree policies (bars, cars, outdoors, etc) Product labelling and modification Reducing accessibility/supply (e.g. retail sector,
smuggling) Etc
Five points about methods
Intensification is essential Individual smoking cessation support vs
population based measures Evidence-based as possible Focus on methods for high prevalence groups Consider additional strategies
Priority areas for new research and testing interventions
Retail interventions (beyond PoS and minor access)
Product labelling and modification• Mandated additive disclosure• Harm reduction approaches (safer cigarette)• Nicotine reduction• Additive removal
Possible retail interventions• Sales to minors
• Sales/use ban, education of retailers, test purchases, public education
• Sales staff > 18 years, > 18 years only customers in tobacco shops
• Marketing and counter marketing• Warning signs• Ban PoS displays and ads
• Licensing• Mandatory license lost if
conditions breached • +/- Fees/auctions for licenses(or
incentives not to stock tobacco)• +/- Community control• +/- Restrictions on
numbers/density/moratorium on new licenses
• Accessibility• Restrict number/density of outlets e.g min
distance between outlets, max density, opening hours
• Restrict proximity (e.g. to schools)• Restrict type of venue/retailers (e.g. no
events where >xx% underage, no venues where alcohol sold/consumed, specialist tobacconists only, no mobile sales)
• Others• Mandate NRT etc sales + cessation
support info available• Mandate provision of sales data, tobacco
industry communications• Government retail monopolies• Minimum price controls• Max purchase per day• License smokers
Population support for retail interventions
Source: HSC 2008 Health and Lifestyles Survey Thomson et al. N Z Med J. 2010;123(1308):106-111.
66% agree, 20% disagree with reducing number of retailers that can sell tobacco
Smoker support for retailer restrictions
Agree or strongly agree that tobacco products should only be sold in special places where children are not allowed to go:
Maori - 67%; European/other - 59%
Edwards R, Wilson N, Thomson G, et al.. N Z Med J 2009;122: 1307.
Endgame – overarching strategies
May be needed to achieve endgame goals within reasonable timeframe
Examples:• Regulation of nicotine content• Rapidly escalating tax and duty on tobacco products• Progressive increase in legal age of purchase for next generation• Progressive reduction in retail supply
• ‘Sinking lid’ on tobacco imports• Structural changes to tobacco market (e.g. regulated market model)
Sinking Lid + Adjunct timing/phasing10% absolute reduction in tobacco products
released for sale per year
2010 2012 2014 2016 2018 2020
To
bacco
Im
po
rts
Massive cessation support, mass media + 90% health warnings
Display free stores; Plain packaging; no duty free
Licensing retailers; reducing license numbers
Alternative nicotine delivery systems
Altering tobacco (e.g. zero nicotine cig.)
Thomson et al. Tobacco Control 2010; 19: 431-435
Some thoughts about the how?
Population vs individual cessation approaches What methods? Some building blocks for success
Building block 1: Ongoing generation and use of evidence
Generate, disseminate and use evidence of effectiveness at population level and for impact on priority populations
Systematic evaluation culture Ongoing research to identify and scope new challenges and
issues Monitoring of progress at population level, including:
• Overarching key markers of denormalisation and social norms (e.g. Chapman and Freeman, Tob Control 2008; 17: 25-31)
• Population quitting tendency (e.g. Tang et al. - Tob Control 2010; 19: S1 56-61.
Evaluation Culture Imperative to carry out thorough evaluation
• Dearth of evidence (used by opponents)• Good practice
Evaluation should be:• Planned• Informed by theory and previous data/literature• Multi-faceted (methods, populations, settings) and
rigorous• Adequately resourced
Scottish SF Legislation1. Semple S,, et al. Bar workers' exposure to second-hand smoke: the effect of Scottish smoke-free legislation on occupational exposure. Ann. Occup. Hyg.
2007;51(7):571.2. Semple S, et al. Secondhand smoke levels in Scottish pubs: the effect of smoke-free legislation. Tob. Control 2007;16(2):127.3. Richmond L, et alI. Impact of socioeconomic deprivation and type of facility on perceptions of the Scottish smoke-free legislation. J. Public Health
2007;29(4):376.4. Phillips R, et al. Smoking in the home after the smoke-free legislation in Scotland: qualitative study. BMJ 2007;335(7619):553.5. Pell JP, et al. Smoke-free legislation and hospitalizations for acute coronary syndrome. N. Engl. J. Med. 2008;359(5):482-91.6. Pell JP, Haw S. The triumph of national smoke-free legislation. Heart 2009;95(17):1377.7. Pell J, et al. Secondhand smoke exposure and survival following acute coronary syndrome: prospective cohort study of 1261 consecutive admissions
among never-smokers. Heart 2009;95(17):1415. .8. Pell J et al. Smoking Ban Significantly Reduces Acute Coronary Syndrome Admissions. JCOM 2008;15(10).9. Mackay D, et al. Smoke-free legislation and hospitalizations for childhood asthma. N. Engl. J. Med. 2010;363(12):1139-45.10. Lewis SA, et al. The impact of the 2006 Scottish smoke-free legislation on sales of nicotine replacement therapy. Nicotine & tobacco research
2008;10(12):1789.11. Hyland A, et al. The impact of smokefree legislation in Scotland: results from the Scottish ITC Scotland/UK longitudinal surveys. The European Journal
of Public Health 2009;19(2):198.12. Hilton S, et al. Expectations and changing attitudes of bar workers before and after the implementation of smoke-free legislation in Scotland. BMC
Public Health 2007;7(1):206.13. Heim D, et al. Public health or social impacts? A qualitative analysis of attitudes toward the smoke-free legislation in Scotland. Nicotine & tobacco
research 2009;11(12):1424.14. Haw SJ,et al. Legislation on smoking in enclosed public places in Scotland: how will we evaluate the impact? J. Public Health 2006;28(1):24.15. Haw SJ, Gruer L. Research: Changes in exposure of adult non-smokers to secondhand smoke after implementation of smoke-free legislation in
Scotland: national cross sectional survey. BMJ 2007;335:549.16. Haw SJ, Gruer L. Changes in exposure of adult non-smokers to secondhand smoke after implementation of smoke-free legislation in Scotland:
national cross sectional survey. BMJ 2007;335(7619):549.17. Goodman PG, et al. Are there health benefits associated with comprehensive smoke-free laws. International Journal of Public Health 2009;54(6):367-
78.18. Fowkes FJI, et al. Scottish smoke free legislation and trends in smoking cessation. Addiction 2008;103(11):1888-95.
Building block 2: Visions, framing and tactics
Need cast iron case and rationale for radical tobacco control measures.
Develop and promote a credible and inspiring vision.
Identify leaders who can communicate and advocate for the vision.
Pay careful attention to advocacy tactics and framing - danger of creating stigma and portrayal as paternalistic, authoritarian etc.
Building block 2: Visions, framing and the case for action
Need cast iron case and rationale for radical tobacco control measures.
Develop and promote a credible and inspiring vision.
Identify leaders who can communicate and advocate for the vision.
Pay careful attention to advocacy tactics and framing - danger of creating stigma and portrayal as paternalistic, authoritarian etc.
The Moral Case for Intervention
1. Smoking is a uniquely hazardous consumer product2. Most smokers start young3. Hardly anyone starts smoking as a mature adult4. Most smokers want to quit5. Smoking is highly addictive6. Stopping smoking is very difficult (and the methods to help are
not very effective)7. Almost all smokers regret starting8. Virtually all smokers don’t want their children to start smoking9. Smoking causes and exacerbates health inequalities and
poverty10. Secondhand smoke harms non-smokers, including children
The Moral Case for Intervention
1. Smoking is a uniquely hazardous consumer product2. Most smokers start young3. Hardly anyone starts smoking as a mature adult4. Most smokers want to quit5. Smoking is highly addictive6. Stopping smoking is very difficult (and the methods to help are
not very effective)7. Almost all smokers regret starting8. Virtually all smokers don’t want their children to start smoking9. Smoking causes and exacerbates health inequalities and
poverty10. Secondhand smoke harms non-smokers, including children
Exploring an oxymoron: Smoking as an 'informed choice'
Combined qualitative and quantitative exploration of informed choice among young adult smokers:• Knowledge of smoking’s addictiveness and range of health risks
of smoking• Estimates of likelihood of addiction, continued smoking and
health risks (? optimism bias)• Beliefs about value of later life (? degree of discounting,
telescoping)• Circumstances of onset of smoking experimentation and
becoming a regular smoker (social pressures, alcohol) and impact of knowledge and understanding of risk
Compare findings with tobacco industry arguments
Building block 2: Visions, framing and the case for action
Need cast iron case and rationale for radical tobacco control measures.
Develop and promote a credible and inspiring vision.
Identify leaders who can communicate and advocate for the vision.
Pay careful attention to advocacy tactics and framing - danger of creating stigma and portrayal as paternalistic, authoritarian etc.
Head to headThomson G, et al. Should smoking in outside
public spaces be banned? Yes. BMJ 2008;337:a2806
VsChapman S. Should smoking in outside public spaces be banned? No. BMJ 2008; 337:a2804
Smokefree Parks in New Zealand
Stigmatisation and the experience of stigma
Tatton L. Smoker stigmatisation: an unintended consequence of smoking denormalisation. Univ of Otago.McCool J et al. Defending the absurd: interpretations of smokers and smoking. Unpublished paper.
“They think we smell. They try and preach to you. It is really frustrating and annoying.”
“God they’re a pain in the ass. They keep ranting and ranting about the bad things of smoking .. the smell of it. If they don’t like it they can go away.”
“She called me a disgusting creature …”
“It does smell really bad, you do the whole kind of wee bit of a cough as you walk past. Just to make sure that they know that you don’t really approve of it.”
Smokers are always pushed out into the outside, away from the non-smokers … it makes you feel .. like the odd one out.”
They just try and make you feel .. Guilty .. And crap about it… It just makes me want to go and have a cigarette [laughs] .. Just to spite them.”
Means as well as ends are important
Means matter in public health and health promotion
Bottom-up, broadly-supported, fully debated measures more acceptable, empowering and sustainable
Hard won gains may be a blessing
The Ottawa Charter for Health Promotion (1986)
Build public policies which support health Create supportive environments Strengthen community action Develop personal skills (empowerment) Re-orientate health services
The Ottawa Charter for Health Promotion (1986)
Build public policies which support health Create supportive environments Strengthen community action Develop personal skills (empowerment) Re-orientate health services
Means as well as ends are important
Means matter in public health and health promotion
Bottom-up, broadly-supported, fully debated measures more acceptable and sustainable
Hard won gains may be a blessing
Structure
What do we mean by tobacco controlled? Achieving the vision
• It is possible!• Some challenges• Some thoughts about the how?
Another (even bigger) challenge Conclusions
Deprivation profile of the European and Other ethnic groups
1 = least deprived 10 = most deprived
0
50000
100000
150000
200000
250000
300000
350000
400000
1 2 3 4 5 6 7 8 9 10
NZDep96 index of deprivation
Usually resident
population
Deprivation profile of the Maori ethnic group
1 = least deprived 10 = most deprived
0
20000
40000
60000
80000
100000
120000
140000
160000
1 2 3 4 5 6 7 8 9 10
NZDep96 index of deprivation
Usually resident
population
Deprivation profile of the Pacific Island ethnic group
1 = least deprived 10 = most deprived
0
10000
20000
30000
40000
50000
60000
70000
1 2 3 4 5 6 7 8 9 10
NZDep96 index of deprivation
Usually resident
population
Can the endgame be achieved for all without addressing broader structural determinants?
Achieving mass cessation in high prevalence groups is a huge challenge
Danger of achieving the endgame only for some and persisting smoking viewed as a problem for a marginalised section of society – which can be ignored.
Structure
What do we mean by tobacco controlled? Achieving the vision
• It is possible!• Some challenges• Some thoughts about the how?
Another (even bigger) challenge Conclusions
Questions for you What might the vision or endgame scenario look like for you? What measures will work in your setting? How can you ensure that the endgame vision is
communicated to all sections of the community and key stakeholders?
How can you make the paradigm shift, develop a credible and inspiring vision and strategy, and achieve your endgame?
How can you ensure that you are part of the movement for wider change to achieve broader public health goals and social justice?
Kia oraThank you