Progress on smoking control in Western AustraliaBMJ 1994; 308 doi: https://doi.org/10.1136/bmj.308.6925.395 (Published 05 February 1994) Cite this as: BMJ 1994;308:395
- A W Musk,
- R Shean,
- N Walker,
- M Swanson
- Correspondence to: Ms Walker.
- Accepted 6 January 1994
In 1990, 20 years of compaigning by the Western Australian branch of the Australian Council on Smoking and Health succeeded in getting tobacco advertising banned in Western Australia and a fund set up to replace the sponsorship of sport by tobacco companies. The council coordinated the activities of the mainly professional medical organisations that formed its members, ensuring that messages about the dangers of tobacco were consistently presented from different angles. The campaigners also ensured that medical data were reworked for presentation to decision makers and public, invaded the corporate world, and minimised opposition by enlisting the support of sportspeople opposed to tobacco sponsorship. The council hopes now that elimination of advertising will reduce the prevalence of smoking.
In 1990 the parliament of Western Australia passed a law to ban tobacco advertising. This legislation came after two failed attempts in the early 1980s and after 20 years of campaigning by the Australian Council on Smoking and Health. Thus the David and Goliath contest between tobacco and health ended in victory for David - as we predicted in 1985.1 The battle was not easy, however, and lessons learned during our conflict in Western Australia may be useful to groups in other countries trying to achieve similar victories.
* Reworking research into new forms is a fundamental task of all compaigners: ‘People behind the Statistics' was written by the council and published by the health department of Western Australia
The first Western Australian statute applied to tobacco was a 1911 law which prohibited smoking in cinemas and theatres. Six years later the Tobacco Act of 1917 made the sale or supply of cigarettes to children under 18 years illegal. There were then no new controls on tobacco in Western Australia for another 55 years.
Following the increasing awareness about the harmfulness of smoking the issue of controlling tobacco use has been high on the public health agenda in Australia. In 1967 the Australian Council on Smoking and Health was established. In 1972 health warnings on cigarette packets became mandatory throughout Australia.2 Other legislation included a federal ban on cigarette advertising on the electronic media (1976), revised health warnings on cigarette packs (1987), and a ban on smoking on all domestic airline flights (1987).2 Until 1990, however, tobacco advertising was permitted virtually anywhere, and certainly in newspapers and magazines and on billboards. In 1990 not only did Western Australia prohibit tobacco advertising; federal legislation banning tobacco advertisements in the print media also came into effect.
In 1978 the Western Australian office of the Australian Council on Smoking and Health took over the functions of the national organisation from New South Wales. The council confirmed its aim of seeking a ban on cigarette advertising and in 1979 formed a legislation committee to coordinate the drafting of a parliamentary bill.1
Modelled on legislation in Singapore and Norway, the Tobacco Products Advertising Bill was introduced into, but failed to pass through, the state parliament in both 1982 and 1983. The main opposition came from sporting bodies because of concerns about future sponsorship but also possibly because of loyalty “bought” through previous sponsorship. The issue of sports sponsorship remained one of the major impediments to legislation in the following years.
In the meantime - possibly as a result of exposure to health campaigns - the government increased the state tobacco tax, and $2m a year from this tax was allocated to establish a smoking and health programme within the public health department of Western Australia.1 This initiative was supported by the opposition parties (who had opposed an advertising ban), and there was widespread support for the “quit” campaigns to reduce smoking rates. In 1984 the Labor Premier Brian Burke said that he would not introduce anti-tobacco legislation before the next state election. Once the Labor government was returned in 1986 the council re-established its legislation committee with the aim of encouraging the government to initiate legislation.
By 1988, however, with another state election approaching, the council realised that the government was not going to introduce the legislation into the current Parliament. It then formed a strong alliance with the Australian Medical Association and launched many campaigns. These campaigns, along with the residual support for legislation to phase out cigarette advertising from the 1982 and 1983 legislation attempts, meant that there was increasing support within parliament for such legislation. At the same time support was enlisted from the National party, which traditionally forms a coalition with the Liberal party when in government. The spokesperson for health in the National party, general practitioner Dr. Hilda Turnbull, was committed to smoking control measures. After intense debate within her party a resolution was passed at its 1989 state conference “That all mediums of tobacco advertising be banned” (C Varvell, personal communication, 1991). Next, a media compaign was combined with letters and deputations to every member of parliament. On 24 August 1989 the Labo premier, Peter Dowding, announced that he would introduce legislation to ban tobacco advertising and establish a health promotion foundation from tobacco taxes which would buy out tobacco sponsorship of sporting bodies.
Intense lobbying continued throughout the passage of the legislation, and the bill's passage was delayed. Nevertheless, in December 1990 it passed with only token opposition from conservative stalwarts on the last day of sitting of the Western Australian parliament. Although the Australian Council on Smoking and Health could not claim total credit for the legislation, the part it played in the 20 years leading up to this success - and the way it played it - was critical to the change of heart of legislators in the state.
* Winning entry in the “cough up an ad” competition 1987, from Nathalie Maron, aged 14
Lesson one: identify realistic objectives and priorities
The commitment of several professional medical bodies and individual doctors led to the information of the Australian Council on Smoking and Health (Western Australia) in 1971. The Council's “inaugural goals” were the labelling of cigarette packets with tar and nicotine levels; the reduction of smoking on public transport and in other public places; encouraging doctors, nurses, public health workers, and parents to set an example by not smoking; encouraging research; and political action. The need for legislation to control tobacco advertising and marketing was also identified as a high priority at this early stage. These goals were seen as being realistic and achievable, although 20 years elapsed between setting the last of these goals and achieving a positive result.
Lesson two: coordinate professional networks
The major strength of the Australian Council on Smoking and Health has been the commitment to the single issue of smoking of a large number of reputable and conventional professional organisations (listed in the acknowledgements). These organisations' nominees formed a core of regular council members. A modest amount of government and private funding allowed for a small full time staff of able and committed professionals to complement the expertise and execute the decisions of the council.
An organisation with such a wide membership can create a critical mass of energy, ideas, and activity; and a key function of this “single issue organisation” has been to coordinate the activities of its member organisations. Publicity on the effects of cigarette advertising from groups such as the National Heart Foundation, the Cancer Foundation, and the Public Health Association as well as the royal colleges of surgeons, physicians, and general practitioners not only provided a consistent message. It also allowed each organisation to elaborate on different aspects of the topic. The overall effect was a perception of smoking as an issue that concerned the general medical and health community rather than just one single purpose organisation. In addition, academic professional associations such as the Thoracic Society of Australia actively supported the council. Their internal support for tobacco legislation through policy and practice (such as not permitting tobacco funded research proposals to be presented at professional meetings) provided even greater motivation to members to make the message public.
The joint efforts of the council and the Australian Medical Association were a critical factor in the struggle to achieve legislation in Western Australia. High profile deputations from the Australian Medical Association ensured good publicity for both the association and the smoking control message.
Lesson three: educate the decision makers
The dissemination of credible, scientific information in a form that the general public could understand provided a basis for changing attitudes to tobacco. We provided information at every opportunity. Council members appeared before parliamentary committees displaying pathology specimens of human lungs affected by emphysema and cancer as well as x ray films indicating vascular disease and other smoking related diseases.
Reworking old research data into new digestible forms is a fundamental task which must be remembered in all health promotion campaigns. Health professionals must not expect science alone to win the war. Scientists often assume - incorrectly - that because the evidence convinces them it will convince others too. The lay public will never tune into more than one or two scientific statements. It is better to give them those fundamental pieces of information over and over, perhaps expressed in different ways, rather than to perplex them with science.
Lesson four: a spoonful of sugar helps the medicine go down
We found that many decision makers were resistant to dry presentations. By “creative epidemiology” - reworking medical data into new and meaningful media stories - the council achieved a high profile, not only within Western Australia, but nationally and even outside the country. The techniques included regular media releases, usually focusing on smoking and children; well planned campaigns; and even shameless gimmicks. The gimmicks included an alternative tobacco company annual general meeting, in which some of the medical royal colleges and other prestigious health groups combined forces to present “the type of AGM which the tobacco industry would hold if it was truthful.” These tactics ensured that smoking was in the news week after week. They also ensured that the council was not only given the credibility that accrues to the medical profession but also regarded with good humour. This last, in particular, helped to minimise the effects of the “fanatic” label often given to the council by the tobacco industry.
Lesson five: invade the corporate world
The council also ventured into the world of commerce and bought small parcels of shares in tobacco companies for reselling to some of its members as single shares. The shareholders exercised their shareholder rights at the annual general meetings of tobacco companies by raising questions about deaths caused by smoking during the preceding year. In 1988 the council offered to support the takeover of a tobacco company by Sir Ronald Brierly, a New Zealand businessman, on the condition that it diversify from tobacco investments. It was hardly surprising that 17 shareholders, each with a single share, failed to help secure national control of this multinational organisation, but their attempt did inject some humour into the media coverage which ensued - and also ensured that the health message was heard yet again.
* Health message replaces a billboard tobacco advertisement at a football ground
Lesson six: personalise the issue
We found that personalising the statistics on smoking and health was an extremely valuable tool when lobbying politicians. The “smoking death card” project coordinated by the council for the Western Australia branch of the Australian Medical Association was modelled on the British Medical Association's “black edged” card project: participating doctors sent postcards to their parliamentary representatives which read “A patient of mine who lived in your electorate died of……It is my opinion that the major cause of this person's death was cigarette smoking.”3 This campaign generated a high level of public interest. More importantly, it reminded politicians that not only did they hold partial responsibility for such deaths but also that political action could help to prevent similar ones.
Lesson seven: develop a strategy and stick to it
The campaign to raise public awareness about the smoking epidemic in Western Australia was conducted in well defined but overlapping stages. The first stage was to influence the general population. The second was then to encourage the general population to influence politicians to follow. The third was to exert direct influence on those politicians, already receptive through the pressure from their electorate, to bring about new legislation. The fourth stage was that the change in legislation would in due course change the attitudes and behaviour of the general population. As these campaigns continued, the breadth and depth of support in the community rose progressively and continues to rise to the day, evidence that the council's strategies were effective. Unless there is a strategy there is an implicit danger that we will win many small conflicts but makes no real headway. Indulging in ad hoc activities is futile unless they are part of some wider plan.
Lesson eight: recruit a team of supportive community members
We found that many community groups and individuals in Western Australia were concerned about the health effects of tobacco. We encouraged our affiliated groups such as the Non-Smokers' Movement and other individuals, including academics and doctors, to write letters to newspapers expressing their opinions. Parliamentarians who represented country areas were particularly sensitive to the influence of doctors in their electorates, and letters reflecting personal and local issues indicated widespread community awareness of the smoking issue, which in turn influenced the actions of politicians.
Lesson nine: minimise the opposition and maximise supporters
One of our strategies established during the campaign to ban tobacco promotion was that of minimising potential opposition (and maximising support). In August 1989 the council conducted a public campaign in conjunction with the Australian Medical Association, of which one specific component was SWATS (Sports Without Any Tobacco Sponsorship): a register of prominent and successful sports people opposed to tobacco sponsorship. This campaign acknowledged that mass change of previous loyalty to tobacco companies from sportspeople was unlikely, but aimed to pre-empt any criticism of legislation by seeking support for the general principle of phasing out tobacco sponsorship and replacing the lost revenue. Most importantly, the council emphasised the need to fight the right opponent - the tobacco industry. In all of its campaigning, the council was very clear that it was against smoking - and not against smokers.
In the Bible David was sustained by both moral righteousness and a carefully developed stratagem in his altercation with Goliath. With patience and careful aim he defeated his physically superior opponent. Similarly, in Western Australia the encounter between the relatively small but morally righteous health interests and the corporate colossus of the tobacco industry has resulted in a victory for health after a protracted contest.
The victory was the result of a combination of tactics, including the coordination of professional networks, the education of decision makers, the recruitment of a team of supportive community workers, and the minimisation of opposition. But most importantly, it was a victory brought about by strategic planning and execution.
Last December saw the third anniversary of the Tobacco Control Act. The legislation has ended the distribution of free samples and competitions involving tobacco products, raised the penalties for the sale of tobacco to minors, prohibited tobacco sponsorship, and established the Western Australian Health Promotion Foundation. It will also restrict tobacco advertising to the point of sale only from July 1994, when the last outdoor billboards are removed. The council and other advocates of smoking control will continue to work for an end to all remaining forms of tobacco promotion, for further increases in tobacco taxation as a disincentive to smoking (particularly among children), for smoking prevention programmes in schools, and for smoke free public places.
The foundation members of the Australian Council on Smoking and Health (Western Australia) included representatives from the Royal Australian College of General Practitioners (Western Australian faculty), the Asthma Foundation of Western Australia, the Australian Medical Association (Western Australian branch), the Cancer Foundation of Western Australia, the College of Pathologists of Australia (state committee, Western Australia), the Conference of Seventh Day Adventists (Western Australian region), the Department of Public Health of Western Australia, the Health Education Council of Western Australia, the National Heart Foundation (Western Australian division), the Royal Australasian College of Physicians, the Royal Australasian College of Surgeons, the Thoracic Society of Australia (Western Australian branch), and the Tuberculosis and Chest Association of Western Australia.
Many people have made important contributions to smoking control legislation in Western Australia, including B K Armstrong, H R Elphick, R M Porter, K W Faulkner, M M Daube, and other past and present councillors of the Australian Council on Smoking and Health; Tom Dadour; Barry Hodge; Judyth Watson; Hilda Turnbull; Stephen Woodward; Suzannah Carter; Glenice Porter; Jude Comfort; and the Western Australian Smoking and Health Program.