Interview with Professor Mike Daub

232 PUBLIC HEALTH PANAROMA VOLUME 6 | ISSUE 2 | JUNE 2020 | 232 – 339 Professor Mike Daube AO is an Emeritus Professor at the Faculty of Health Sciences, Curtin University, Australia, and an expert on issues related to tobacco, alcohol, public health, health promotion and health policy. He was formerly Director-General of the Department of Health of Western Australia and Chair of the Australian National Public Health Partnership. He was also Chair of the Australian Government’s expert committee that recommended tobacco plain packaging as part of a comprehensive approach. You have played an instrumental role in reducing the toll of tobacco with strategic, long-term advocacy that has placed Australia in the spotlight as a global leader in tobacco control, particularly with the ground-breaking introduction of standardized packaging in 2011. Australia's success has set in motion a domino effect throughout much of the WHO European Region, with the European Union following suit with standardized packaging legislation in 2014. What was the foundation of this success? We have been fortunate in Australia, as in a range of other countries, to see a dramatic decline in smoking over time, in both adults and adolescents. Not enough of course, but nonetheless, in the words of a former Australian Prime Minister, it has been one of the great public health successes. Progress like this doesn’t come from one-off miracle measures – it comes as a result of comprehensive approaches implemented over time. So we have had innovative public education programmes, tobacco advertising bans, smoke-free measures, further curbs on tobacco promotion (such as an end to point-of-sale marketing, and of course plain packaging), cessation support, special programmes for disadvantaged groups, and much else. And all of this has been underpinned by strong advocacy, supported by our leading health and medical organizations. There has been outstanding leadership from a range of European countries over many years, from research to action. In Australia, as in Europe, many of the heroes responsible for the progress we now see are no longer with us, but they are the people who developed and acted on the early evidence. They started the advocacy and other major programmes at a time when the industry was still immensely powerful, and there was much less recognition of the magnitude of the problem. They showed the way and we are all in their debt. Tobacco product regulation is a powerful, albeit underutilized, tool which can be a game-changer in reducing and even eliminating tobacco use. The tobacco industry has thrived on years of little or no regulation. What are the conditions that would support or impede success in developing and implementing regulatory interventions to reduce the addictiveness of tobacco products? PANORAMA PEOPLE Interview with Professor Mike Daube By Jonathan Ewing 233PANORAMA PEOPLE ПАНОРАМА ОБЩЕСТВЕННОГО ЗДРАВООХРАНЕНИЯ ТОМ 6 | ВЫПУСК 2 | ИЮНЬ 2020 Г. | 233 – 339 Every measure proposed that might actually succeed in reducing smoking is fiercely opposed by the tobacco industry and its allies. Their arguments are familiar – it won’t work, soft approaches are better than anything tough, voluntary action is better than legislation, more research is needed, there will be public resentment, groups such as retail outlets or media and sports that accept tobacco funding will be harmed – and above all, they argue against anything new being done that might reduce their sales. But our experience over the years is equally familiar: the evidence-based measures recommended by health authorities work, from advertising bans to smoke-free environments, and from strong public education campaigns to plain packaging. And we have also learned that once a new component of the strategy has been implemented successfully in one country, it is speedily followed in many others. Who would have thought only a few years ago that we would now have plain packaging either in place or on its way in more than 20 countries? But we have also learned that the tobacco industry will not go away. They are powerful, determined, and above all, good at one thing: selling and marketing addictive, lethal products to every possible market – adults, children and disadvantaged groups. And the more they oppose a measure, the more effective we know it will be. You were awarded the prestigious Hugh Leavell Award for Outstanding Global Health Leadership in 2017. In that year’s Leavell Lecture you offered 11 commandments in public health advocacy, with the 11th commandment being “oppose and expose the opposition.” Novel and emerging tobacco products, touted by some as “harm reduction” or “cessation” products, create another layer of interference by the tobacco industry and related industries. The existence of such products has revitalized claims by the industry that they should be involved in the decision-making related to implementation of the WHO Framework Convention on Tobacco Control (WHO FCTC), and has led to further misrepresentation of Article 5.3 of the WHO FCTC (on interference by the tobacco industry). What is your response to such claims? When I started working on tobacco in the early 1970s as the first full-time Director of Action on Smoking and Health (ASH) in the United Kingdom, there was some measure of excuse for the people leading the industry. Most of them had started working in tobacco before there was broad awareness of the evidence on the harms of smoking. But now, 70 years after the first incontrovertible evidence on smoking and lung cancer, and with so much further evidence on so many other conditions, anybody who works in the tobacco industry does so in the full and certain knowledge that millions of people around the world will die as a result of their work. They are tougher, more ruthless and more cynical, so we cannot afford to relax. The tobacco industry is now fighting back more aggressively than at any time I can recall over the past 50 years. Our task is to keep pressing on with the measures they oppose so fiercely. The tobacco industry wants to be involved in discussions on policy about smoking so that it can disrupt, delay and prevent anything from happening that will run counter to its interests. Article 5.3 and the guidelines for implementation of that Article are absolutely right: “There is a fundamental and irreconcilable conflict between the tobacco industry’s interests and public health policy interests…” Parties should protect the formulation and implementation of public health policies for tobacco control from the tobacco industry to the greatest extent possible.” The WHO FCTC was a ground-breaking approach to international cooperation on a priority public health issue. The 2016 WHO FCTC expert review group, on which I was privileged to serve, concluded that the WHO FCTC has made a powerful contribution to tobacco control policy development and implementation, strengthening existing strategies, and denormalizing smoking, and has undoubtedly played a critical role as an authoritative and agreed catalyst and framework for action, and that countries that have implemented WHO FCTC policies at high levels have generally experienced greater reductions in smoking prevalence. As with any global process, implementation will not be uniform, but the WHO FCTC has played a critical role in ensuring better, stronger action around the world. There is a wealth of evidence that the WHO FCTC gives legitimacy to strong measures and has initiated, supported and enabled evidence-based action to tackle tobacco use. Its impact on transforming global health on a grand scale has been undeniable. Is tobacco unique in this respect, or could similar treaties be considered to advance work on other noncommunicable diseases where action is opposed by powerful vested interests? Regulation is clearly a critical component in terms of reducing the harms caused by smoking and the capacity of tobacco companies to market and promote their lethal products. Key components here are sound evidence, strong and consistent advocacy from health groups, determined leaders within 234 PANORAMA PEOPLE PUBLIC HEALTH PANAROMA VOLUME 6 | ISSUE 2 | JUNE 2020 | 234 – 339 governments (at both political and bureaucratic levels), and proper implementation of Article 5.3 of the WHO FCTC, which precludes the tobacco industry and its allies from participation in the policy process. It will also be important for governments and health groups alike to continue exposing the lies and deceit of tobacco companies from the earliest times to the present day. Other areas such as alcohol, junk food and gambling could benefit from our experience with tobacco and develop their own treaties (especially including an equivalent to Article 5.3). What can the European Region do now? The European Region has been a leader in tobacco control from the earliest years. The first major, internationally recognized report on the harms of smoking came from the Royal College of Physicians in the United Kingdom in 1962, of course following the publications of Doll and Hill and others in the 1950s. The Nordic countries – notably Norway, Finland and Sweden – were leaders in acting on tobacco advertising, health warnings and taxation. Ireland was a leader in implementing smoke-free measures. These countries and others have made critical contributions over the years to tobacco control not only in Europe but much more widely. While we rightly celebrate the achievements of the past, we must also recognize that 70 years after the publication of clear evidence that smoking was lethal, and 50 years after the first World Health Assembly resolutions on tobacco, we are a long way off achieving smoke-free societies, and some countries still have much work ahead even to see tobacco control as a priority. As I have commented elsewhere, business as usual will see some reductions in smoking, but also a continuation of 8 million deaths annually for decades to come. So we need a new approach globally that recognizes the need for a new impetus, with new targets, focusing above all on both the comprehensive approaches and the specific measures that will generate smoke-free societies. This will require strong support for the measures in the WHO FCTC, rather than simply aspirational wording. It will require countries to set specific targets for action by specified dates. It will require commitment of resources appropriate to our largest preventable cause of death and disease. And it will require an absolute and unequivocal commitment to opposing the tobacco industry globally and locally. It is time to start talking clearly about target dates for an end to smoking and an end to the commercial tobacco industry. That might seem an ambitious target, but so were measures such as advertising bans, smoke-free measures and plain packaging. When I did the first survey of smoking in aeroplanes in 1973, I was solemnly assured by one major European airline that restrictions on smoking in aircraft were technically impossible, but now they are the norm. Simply put, if there were no commercial tobacco industry, cigarette smoking would by now be a distant memory. The WHO European Region has a terrific record on tobacco. As a result of action by many Member States working with WHO, Europe is better placed than any other region to develop a programme to phase out the commercial sale of tobacco, which would in turn and in a relatively short time bring an end to smoking and save millions of lives. Disclaimer: The interviewee alone is responsible for the views expressed in this publication and they do not necessarily represent the decisions or policies of the World Health Organization. n