Legislative Council Tuesday 23 March, 2021

Ms FORREST (Murchison) - Mr President, I also acknowledge the work of the member for Windermere over many years on this major health issue. It is not something he has been working on with this bill; it is something he has been passionate about since my time here. It is not something that has suddenly become apparent to him - he has always been a bit of stickler for this, and for foxes.

I hope I can get through my speech. Members will notice I have a cough. It is completely unrelated to smoking and it is also unrelated to COVID-19. It is asthma and I am having a bit of a challenge with it.

Smoking nicotine-based products are harmful and extremely addictive and there is no safe level of use. We know there are very real health impacts associated with every cigarette smoked. Even used as intended, this harmful product will negatively impact on the person smoking it and those in the vicinity of that smoker. Personally, and I have said this many times in this place, I abhor smoking. I abhor being in a venue where people are smoking or when you have to walk through the crowd of smokers outside some venues, when they used to be able to smoke inside venues. Particularly as a nurse when looking after patients, and I have spoken about this before, when they are coming out of anaesthetic, it is most unpleasant when you are extubating a patient who is a smoker. You know the difference.

We all know it is harmful and we also know it is very addictive. I am not going to go over all the information that other members have; in particular, the member for Windermere covered the statistics extensively. I will talk for a fairly short time about some of the matters I considered while researching and considering this bill. In doing that, I asked myself a number of questions. I believe it is important to consider these questions in the context of this bill. The key questions are: What is the problem we are trying to address? How big is the problem? How costly is this problem in terms of personal and financial cost to our health system and other related costs?

I also hear some of the comments made by some small business people, driven mainly by Big Tobacco, that drive me insane. To suggest that small business will be impacted by this bill - if it were to be successful, there would be minimal impact. To say that businesses are going to go out of business because of this, or young people are not going to get work is a complete nonsense. We have heard this scaremongering before. Every pub in Tasmania should be closed when we removed smoking from pubs and clubs. Let us not get distracted by those sorts of arguments, which have absolutely no weight.

In an article in Opinion titled 'Up in Smoke: The extraordinary cost of smoking to Australia', published in December 2019, Dr Robert Tait, of National Drug Research Institute, stated:
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Tobacco is responsible for the preventable deaths of over 20 000 Australians each year, and the cost to them and to the wider community is high. New research, conducted by the national team led by NDRI, estimates that in the 2015-16 financial year, smoking cost Australia $19.2 billion in tangible costs, and $117.7 billion in intangible costs, giving a total of $135.9 billion. The first update of the cost of smoking in 15 years, the study estimated the 'tangible' costs of smoking had risen to $19.2 billion.

We simply cannot ignore that enormous cost. I am not suggesting anyone is ignoring it, I am just saying this is the reality.

He goes on:

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This includes $5.5 billion that smokers spend purchasing cigarettes, $5 billion in lost productivity and worker absences, $2 billion for family members caring for someone with a smoking-related disease who effectively contribute to the health budget through their lost earnings, and the cost of $1.7 million hospital admissions to treat smoking-related conditions. Intangible costs, such as the years of life lost from premature deaths in that year or lost quality of life from living with a serious illness, were estimated at a massive $117.7 billion.

These costs fall way short of the $0.43 billion in combined federal and state taxes received in the 2014 year. If we talk about that addiction to taxes, just to repeat those numbers: in 2014 15, when I could make a comparison - it is the most recent comparison I could make - taxes received and the revenues received were $0.43 billion, the cost of $117 billion. In fact, that is not even scratching the surface. You could easily not have to worry about the money we are getting from it if you were not relying on those taxes.

The Australian Institute of Health and Welfare website contains a range of very informative health-related data, including very useful interactive graphs and charts, not just about smoking, but in all areas of health-related matters. They sourced their data from many reliable sources, including the Australian Bureau of Statistics. According to the Australian Institute of Health and Welfare's latest data on tobacco smoking, which was released on 23 July 2020, smoking was responsible for 9.3 per cent of the total burden of disease in Australia in 2015, making it the leading risk factor contributing to disease burden. Almost three-quarters, 73 per cent, of the burden due to smoking was fatal - that is, due to premature death.

In 2015, smoking was responsible for more than one in every eight - 21 000 - deaths; cancers accounting for 43 per cent of the burden of disease, with smoking, and almost two thirds of this was from lung cancer, 28 per cent of the total burden. Chronic obstructive pulmonary disease, accounted for 30 per cent of the burden, followed by cardiovascular diseases, 17 per cent; primarily related to coronary heart disease, 10 per cent; and stroke 3.1 per cent.

Tobacco use has remained the leading risk factor but the disease burden from smoking fell from 10.5 per cent of total burden to 9.3 per cent between 2003 and 2015. After adjusting for age, the rate of disease burden from smoking showed a decrease of 24 per cent between 2003 and 2015, with a greater decrease in males than females. The burden also fell for all six of the leading diseases linked to smoking - COPD, lung cancer, coronary heart disease, stroke, oesophageal cancer and asthma.

However, while the burden linked to current smoking decreased, the burden linked to past smoking - ex-smokers - rose. This is likely to be because some diseases associated with smoking such as lung cancer and COPD can take many years to develop. As a result, the effects of past smoking are expected to continue to have an impact on the disease burden in the near future even if smoking rates continue to decrease.

The member for Windermere provided us with some very relevant statistics. I do not intend to repeat them but I wish to give a summary of the key aspects related to the scale of the challenge and what problems this bill actually seeks to address. The Australian Institute of Health and Welfare's latest update on tobacco smoking figures - as I noted, released in July 2020 - stated that the latest data from the National Drug Strategy Household Survey (NDSHS) estimated that 11.6 per cent of adults smoked daily in 2019.

This daily smoking rate has declined from an estimated 12.8 per cent in 2016 and has halved since 1991 - 25 per cent. Similarly, data from the National Health Survey (NHS) in 2017 18 showed that smoking rates declined steadily over the nearly three decades to 2017 18 and, after adjusting for age, the proportion of adults who were daily smokers has halved since 1989-90. This also provides details regarding trends and demographic data which I will now quote from.

In 2019, the NDSHS reported current smokers aged 18 and over smoked an average of 12.9 cigarettes per day, a decrease from 15.9 cigarettes in 2001. Men and women smoked a similar number of cigarettes per day in 2019 - an average of 13.9 and 12.9 cigarettes per day respectively. In 2019, the proportion of a pack a day - 20 cigarettes or more - smokers increased with age. Two in five people - approximately 40 per cent in age groups 40 and over - smoked more than 20 cigarettes per day compared to one in five or approximately 20 per cent of people aged 18 to 39.

The 2019 NDSHS found that people in their forties and fifties had the highest daily smoking proportions - 15.8 per cent and 15.9 per cent respectively - different from the situation in 2001 when people in their twenties and thirties were the most likely to smoke daily. Between 2016 and 2019 the proportion of people who smoked daily fell for people in their twenties and thirties but there was no change for people in their forties, fifties and sixties.

Over the period of 2001 to 2019 for people aged 18 to 39, the proportion of smoking daily had halved but there has been little improvement among people in their fifties and sixties. We can see where the problem is here - it is in the older people. This would suggest a greater focus is needed to assist older people to give up. Of course, we need to do whatever we can to stop people taking it up but we have still got a major problem in older people who are addicted currently.

We cannot turn our back on them, and I am not suggesting that we are, but that is where the problem appears to greatest at the moment. We need this action as well but if we were to dissuade younger people from taking up smoking, we will have fewer older people needing to give up over time.

Further data sourced from the Australian Bureau of Statistics and reported by the AIHW supports this need and said the proportion of adults aged 18 and over who never smoked increased from 48 per cent in 2001 to 60 per cent in 2016 and remained stable at 61 per cent in 2019. Similarly, findings from the NHS showed the proportion of adults who have never smoked is increasing over time from 52.6 per cent in 2014-15 to 55.6 per cent in 2017-18, or from 52.9 per cent in 2014-15 to 56.1 per cent in 2017-18 after adjusting for age. In 2019, adolescents aged 14 to 17 and young adults aged 18 to 24 were more likely never to have smoked than any other age group - 97 per cent respectively. This proportion remains fairly stable; since 2016, it was 96 per cent and 79 per cent respectively, and represents an increase in the proportion of adolescents and young adults who never smoked since 2001 of 82 per cent and 58 per cent respectively.

It is apparent the overall rates of young people taking up smoking is continuing to slowly fall - that is across the board - however, it is not consistent across all cohorts of all young people and those living in low socio-economic and/or geographically isolated regional areas are having higher rates of uptake than those in the higher socio-economic and suburban areas. A lot of these are people in my electorate and I know in Windemere's electorate too. This was described by the AIHW. The burden of disease attributable to tobacco use is unequally distributed across Australia. In very remote areas, tobacco use was responsible for 10.7 per cent of the total burden of disease, compared to 8.5 per cent in major cities in 2015. After adjusting for age rates, similarly that burden of disease attributed to tobacco use increases as remoteness increases, with remote and very remote areas experiencing 1.8 times the burden of major cities. With regard to the social economic areas, the AIHW noted there was a clear gradient of decreasing burden as social economic position increased.

The lower socio-economic areas experienced the higher socio-economic disadvantage. Tobacco use was responsible for 11.7 per cent of total burden disease compared with 6.5 per cent in the higher socio-economic areas that experienced the least disadvantage. After adjusting for age, it similarly showed the burden of disease attributed to tobacco use was 2.6 times higher in the lowest socio-economic area than in the highest socio-economic area.

We know this is very clearly the case in Tasmania. Any reform program or approach to address this challenge must take these realities into consideration. Therefore, in order to address this challenge, we need to approach this challenge in two ways: we need to stop young people starting smoking and help those who already smoke to stop, particularly those in their forties and above. I asked myself: will this legislative reform address this matter and be effective?

In whatever measures we take and support, we first need to consider the fact it is contributing to smoking, including by young people. I know the member for Elwick talked about education. It is important to note these factors because in my mind there is no point doing anything unless you address the fundamental underlying problem that is clearly in the evidence: people who live in low socio-economic areas are in living in disadvantage, and those living in rural and remote areas are much more at risk, and we need to wrap services around those people to help them. Whatever you to with this legislation will have minimal impact unless you directly target and support those people, put services into those areas - and we are not seeing that and the results speak for themselves.

These factors are socio-economic factors, intergenerational role modelling - parents and other family members who smoke - peer pressure; high levels of impulsivity; poor school performance or school retention; higher alcohol consumption; the belief that having a cigarette is a stress reliever, which is actually the complete opposite if you know the physiology of what a cigarette does to your body - but it makes me feel like I feel now; media advertising and smoking in movies and so. You do not see the advertising anymore but you still see smoking in movies -

Mr Valentine - Actually more so over the last few years.

Ms FORREST - If we consider this list, there are not many areas that directly formally address the issue. It is investment, it is resourcing and it is actually understanding the problem. Government can fund and support effective media and advertising campaigns, and we actually need to do more in this area.

I am sorry I missed some of the Leader's speech - I had a coughing fit and had to leave the Chamber - but she may have addressed that. It has been a long time since we have had an effective campaign designed with the assistance of the at-risk groups to fully understand what might best work in a media campaign.

I have asked several people during my preparation to this debate when the last big serious anti-smoking campaign was - television, billboards, back of buses - no-one can tell me. I think it was about 2013. But who remembers it? You have to have that sort of thing in people's faces all the time because there is a new cohort of 18-year-olds or 21-year-olds or 25-year-olds every year.

Mr Valentine - They rely on the cigarette packet advertising.

Ms FORREST - But it is a very targeted approach and we know where the problems are. I have just told you where the problems are, we all know that.

Governments should consider incentivisation programs as well, in my view, providing financial incentives for those who want to quit. A pilot project has been started in Smithton recently on the Sleep Well, Breathe Well Program; it is the brainchild of (TBC) Dr Maya Friedman, who has done a great deal of research around this. This is actually shown to work. Funding has been provided for 30 places and people actually are not getting money; they are getting vouchers for six-month membership at the local health and wellbeing centre, a swimming centre, which has a gym and everything; depending on meeting those milestones they are getting vouchers to spend in the local community. There is a local community voucher system, and I am sponsoring additional places in that to try to encourage people.

The uptake was really good in one of our disadvantaged communities; I think it will be interesting to see the actual impact. It shows that, at least in previous programs, 20 per cent of people actually give up and stay off cigarettes. The total amount is about $360, so we are not talking huge dollars. We can all do that ourselves, sponsor someone. Vouchers worth $360 to give up; you have to have your CRC monitoring done and sort of thing, and they know if you are lying, but it seems to be an interesting approach that we should perhaps use more widely. It is also a hell of a lot cheaper than many other things.

The Government also needs to fund and support beyond the usual one- to three-year pilot programs that are often tried, particularly for measures shown to be effective in assisting people either not to take up the habit or to quit. This can include carbon monoxide monitoring, and traditional use of vaping should be part of our conversation. We need to have that discussion. I have an open mind on that; I think we do not know a lot that about it, but let us keep all our options open. Accessible nicotine replacement therapy, particularly for those living in so low socio-economic circumstance, because no one method works for everyone.

We can legislate to keep students at school longer - that could help, but it is not going to be a very popular approach. Without actions to address underlying factors contributing to poor school attendance, performance and retention, this in itself will achieve little. We can make policy and budgetary decisions that prioritise addressing intergenerational poverty and disadvantage. We can work to provide adequate secure and safe housing, and access to health care. These are thing we should be doing anyway, but these things will have an impact on the smoking rate over time.

We can legislate to permit the use of evidenced-based smoking cessation measures if regulatory action is needed to achieve this. Smoking cessation must form part of a harm minimisation strategy as well as an overall health policy.

We know prohibition does not work. When I hear members saying 'Well, bring in a bill to ban, and I will support it.' - no, you will not: prohibition just causes black markets. We need to educate people about the harms. Prohibition has not worked in anything really. We will need to focus on reducing demand, helping people quit, and making non-smoking the default position for our youth and adults. This will not be achievable if we do not address the underlying contributing factors.

I have also considered what previous measures taken by the state and federal governments have had a positive impact on the reduction of smoking rates. As history shows, many of the bigger levers governments can pull have already been used. Could they be pulled harder? Possibly.

Increasing taxes seems to be a popular choice, especially for non-smokers. Does this hurt those facing economic hardship even further if it is done without measures to address the underlying factors and provide a full range of quit support measures? A downward trend in smoking among teenagers coincided with the launch in 1997 of the high-profile, media-led nationally coordinated national tobacco campaign and increased tobacco taxes, the introduction of smoke-free environments and stricter enforcement of regulations around sales to minors and smoke-free areas.

A further decline in smoking amongst older teenagers between 2011 and 2014 came in the wake of the launch of an updated national tobacco strategy in 2012 and the implementation of a number of important tobacco control strategies such as plain packaging, large tobacco excise increases, further expanding smoke-free environments and new mass media campaigns. Another major media-led campaign does not require legislative action; it requires a policy decision and a budgetary commitment.

Slower progress in recent years may have been at least partly due to the absence of ongoing government investment in mass media campaigns and the tobacco industry's proliferation of new products and brand names that appeal to young people. We know they target young people mercilessly.

It has been too long in my opinion since we have had a similar campaign. Smoking prevention campaigns usually target teenagers because the studies show that people usually begin to smoke at age 12 to 13. The phenomenon is well known and numerous prevention programs are geared towards teenagers. So what will work?

No one measure will be the answer. A multi-pronged approach is needed as well as addressing the underlying factors associated with intergenerational influence and socio economic disadvantage. Targeted and significant media campaigns designed by young people for young people must be adequately resourced and conducted for an extended period, not just a few weeks or few months. Specific areas that should be targeted are pregnant women, carbon monoxide monitoring, individualised support to quit et cetera.

Support and promotion of education and engagement with education - that is, education generally, not just education about the harms of smoking. Will legislative reform such as the proposed T21 legislation we are looking at now that creates an offence to sell tobacco products to anyone under the age of 21 have a significant impact or any impact at all? In my view it is unlikely to make any measurable difference because we know the highest number of young smokers live in low socio-economic areas and face all the challenges that increase the likelihood they will start smoking early, and usually it is well before the age of 18.

Such reform, however, will not do any harm, and you could argue it sends a message and signals intent. I hear and appreciate the issue raised regarding 18 being the age of majority, the age of consent. Maybe we should question the age of consent at the moment when we look at what is happening in Canberra. Maybe people need a whole better understanding of what consent looks like and when adults are able to make a range of what society considers adult decisions.

Raising the age that a person can purchase cigarettes and tobacco products does not remove their legal right to smoke the product, so again, one could question the likely benefit of such a change. Comparing this with the right to vote, right to drink alcohol, enter and remain in a licensed premises, for example, is only comparable to a degree. I also note that in these matters there are safe levels of interaction with these activities. It is usually quite safe to vote; you can drink alcohol in safe limits, and you can enter a mainly licensed premises without harm generally, but every cigarette causes harm, even when it is used as intended.

Whilst I appreciate these concerns, I do not believe they alone should be barriers to this bill. I am not convinced this bill will have a significant impact on the cohort of smokers identified as being at higher risk of taking up this harmful product. If we are to stop people smoking, we need to address the underlying reasons as a priority and have a government willing to support a targeted mass media campaign aimed at young people, designed by young people and understood by young people.

The question for me overall is: what are the potential benefits of such a move and what are the likely disbenefits or negative outcomes? We know that two thirds of smokers die in middle age due to smoking-related disease and that is about 560 Tasmanians every year. We also know those who survive midlife are much more likely to be presenting to our emergency departments and miss work through sick days, thus having a negative effective on our health system and broader economy.

We also know most teen smokers get their cigarettes from similar-aged peers and peer group influence which is the main reason adolescents start smoking.

I have listened to the other contributions in this debate and hear the comments about this can be discriminatory, it treats people differently but there is no safe level of tobacco use. I think the member for Mersey said that sometimes you have to make tough decisions on these things.

I have already spoken about the impact on business, and the issue of raising the age to 25 years is probably something for another day. If you use that argument then you should use that for sexual consent as well, looking at what is happening at the moment. Mind you, most of the people involved in the bad behaviour in Canberra are not 25.

On balance, I support the bill but in doing so call on all parties to address the underlying factors that contribute to the uptake of smoking and look at all options that may assist current smokers to give up - a very difficult task for most and one where judgment and intolerance and criticism is never helpful.