Lung Cancer Experts Applaud Australia's Tobacco Restrictions

Zosia Chustecka

October 28, 2013

SYDNEY — Oncologists and researchers gathered here at the 15th World Conference on Lung Cancer applauded Australia for being the first country in the world to introduce plain packaging for cigarettes, in addition to restricting advertising at point of sale and elsewhere.

"Smoking is the biggest risk factor for lung cancer. The most effective way to reduce it is to have effective tobacco control, and Australia has led the way on this," said Fred Hirsch, MD, PhD, professor of medicine and pathology at the University of Colorado School of Medicine in Denver. He has just taken on the role of executive director of the International Association for the Study of Lung Cancer, which organized the meeting.

He was speaking at the opening ceremony to welcome the Right Honorable Nicola Roxon who, as Health Minister in 2007 to 2011, worked on introducing the plain packaging legislation, and then later as Attorney General of Australia defended the law when it was challenged in High Court by several tobacco giants, including British American, Philip Morris, Imperial, and Japan Tobacco.

"This set an important precedent," she said. "At the heart of their argument was that plain packaging contravened the constitution by acquiring property on other than just terms."

The High Court rejected that argument by a majority of 6 to 1, and "knocked on the head any suggestion that the government could be prevented from regulating a dangerous product."

The tobacco industry also mounted an intense political and advertising campaign against plain packaging, even claiming that it infringes on international trademark and intellectual property, but ultimately failed in these efforts.

"You can take on the tobacco industry and win," Roxon told the packed audience.

She urged all present to fight against the tobacco industry and to work with governments to introduce restrictions in their own countries. "Tobacco restriction is a preventive measure against lung cancer on a population scale," she said.

If ever there is a global health challenge, this is it. Nicola Roxon

"If ever there is a global health challenge, this is it," she said. "We have 6 million people dying worldwide every year from tobacco-related disease."

An estimated 1.4 million of these deaths are from tobacco-related lung cancer, for which "you pick up the pieces on a daily basis in your working lives," she said, addressing the health professionals in the audience.

"This is a public health intervention that can reduce the harms from smoking, and I am sharing my experience with you in order to urge you to act," she said.

"None of you should underestimate the role that you could play," she added, noting how the government in Australia relied on research studies and input from clinicians and advocates while working on the legislation. She also mentioned in particular working closely with the Lung Foundation of Australia and Cancer Council of Australia.

"Plain" Packaging Bit of a Misnomer

The plain packaging legislation was introduced at the end of 2012, and it was an incremental step in ever-tightening restrictions on tobacco advertising, she explained. As well as comprehensive bans on advertising anywhere, including online, tobacco products are hidden from view at point of sale, locked behind a plain cupboard, so that customers have to ask specifically for cigarettes.

But the packs themselves are alluring, especially to children, and they are attractive to young people, and so "we felt that having decorative branded packs was making a mockery of our strict bans on advertising," she commented.

"Plain" packaging

Plain packaging is a bit of a misnomer, for the cigarette package is anything but plain — it has graphic warnings of the harms of smoking, with photos taking up 75% of the front and 95% of the back of the pack, showing, for example, an emaciated young man dying of lung cancer, a gangrene foot, and a mouth with missing teeth and sores. The remainder of the packaging is a drab brown color ("we researched which was the least attractive," commented Roxon), and the name of the brand appears in white print in a small typeface.

The move has put people off smoking. A study conducted by Cancer Council Victoria during the roll-out phase of the law surveyed 536 smokers and found that, compared with smokers of cigarettes in branded packages, smokers of cigarettes in plain packaging perceived their cigarettes to be lower in quality and less satisfying than a year ago, and were more likely to rate quitting as a higher priority in their lives (BMJ Open. 2013;3:e003175).

"We have heard anecdotally that smokers say their cigarettes do not taste as good, that they are not enjoying them as much, and that friends are objecting to seeing the packaging," Roxon commented.

The "Bryan" package

One package in particular seems to have resonated with customers, who ask specifically not to be given the package containing Bryan — shown in his prime, smiling with a full head of hair, aged 34 years, and then dying, bald and emaciated, only 10 weeks after being diagnosed with lung cancer.

"The glamour image has gone from smoking," Roxon concluded.

The tobacco industry is launching another challenge to the legislation, this time attempting to challenge the right of Australia to make its own decisions in areas that involve international trade agreements, but it may be 2 years or so before there is any action. In the meantime, the legislation will have been in place, and data will be accumulating on the effects of plain packaging on smoking. Roxon is optimistic about the outcome of any such future action, maintaining that in Australia, the glamour image of smoking "has gone for good."

Other Countries Talking About Moves

Other countries have been discussing plain packaging, but none has yet bitten the bullet in the same way that Australia has. Roxon showed packaging from Quebec, in Canada, where graphic health warnings were printed on a cellophane wrapping that covered the branded package, but which could easily be removed and discarded.

In the United Kingdom, advertising cigarettes is now restricted at point of sale, they are locked in plain cabinets out of view, and each package does contain a written health warning and a small graphic, but the brand is still clearly seen, and the packaging remains attractive. There was a move toward plain packaging, but the government recently backtracked.

In contrast to the tight restriction on tobacco in Australia, in the United States "there is hardly any," said Matthew Steliga, MD, assistant professor in the division of cardiothoracic surgery, College of Medicine, UAMS, Little Rock, Arkansas. Cigarettes are on show, and packages carry only a written warning, he said. There was a move to introduce graphic warnings in 2009, but the tobacco industry sued, and the process stalled. The United States is "very strikingly different" from other countries in its First Amendment, which the tobacco industry "hides behind and uses as an excuse for manipulating the public in its marketing of these addictive deadly products," Dr. Steliga commented to Medscape Medical News.

In Australia, the tobacco industry sued the government over plain packaging and the government won, but in the United States, the tobacco industry sued the government and industry won, summarized Paul Bunn, MD, professor of medicine in medical oncology at the University of Denver, who has been executive director of the International Association for the Study of Lung Cancer for the past 10 years. Big money is involved, he commented. "The government should be able to protect its people from harm, but they are not doing that in any shape or form," he told Medscape Medical News.


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