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Economics References Committee
09/03/2016
Personal choice and community impacts

CARPENTER, Dr Anthony, Faculty Policy Advisory Committee, Australasian Faculty of Public Health Medicine, Royal Australasian College of Physicians

CHAIR: I welcome Dr Anthony Carpenter, representing the Royal Australasian College of Physicians. I invite you to make a brief opening statement, if you wish to do so, and then the committee will ask questions.

Dr Carpenter : The Royal Australasian College of Physicians consists of more than 20,000 fellows and members in New Zealand and Australia, across eight divisions, faculties and chapters, covering a broad array of health and healthcare settings, including paediatric and adult medical care, public health and occupational and environmental medicine. The college and its fellows have served the people of Australia and New Zealand for more than 75 years and continue to lead in the provision of medical care, research, and advocacy in protecting and promoting the health of individuals, communities and populations.

The role of physicians is to provide patients and their communities with expert advice, treatment and education; to support and maintain health; and to encourage healthy behaviours. The RACP believes that the government has a key responsibility to protect and promote the public's health through supportive policies and appropriate regulation; through the provision of access to high-quality health care; and by protecting and promoting healthy environments in which people may live and work. Personal choices and community impacts are often inextricably linked—for example, with regard to the harms and costs of alcohol and tobacco use. Multifactorial policy interventions to limit the harms of tobacco to both individuals and those around them have played a major role in reducing the social, medical and economic costs of smoking over the last 30 years. The Royal Australasian College of Physicians believes the health of individuals must continue to be supported by government regulation in order to address environmental factors which are beyond the control of individuals. Public policy has an important role in creating and maintaining an environment in which the Australian public are supported and enabled to make choices that promote their health and wellbeing. The college believes in evidence based evaluation and implementation of public policy to ensure that it is appropriate and proportional to the nature of the health issue being addressed. With regard to this, the role of research and evidence developed by the fellows of the college to support public policymaking is critical. The college and its fellows are committed to continuing to develop and provide high-quality evidenced based guidance to support policy that protects and promotes the health of individuals and populations. The college is grateful for the opportunity to make a submission and to appear before the hearing today. Thank you.

Senator KETTER: I questioned one of the other witnesses about the death of a child in the US after ingesting liquid nicotine. I am wondering if you can tell us about the toxicity nicotine in liquid form in particular?

Dr Carpenter : Thank you for your question. I cannot comment specifically about the toxicology of nicotine. It is not my area of particular expertise. There are fellows of the college who are specialists in addiction medicine. I would have to take that question on notice and get back to you with an answer from them.

Senator KETTER: You are not familiar with that particular case of a young person who died in the US?

Dr Carpenter : I am not briefed on that particular case. I apologise, but I am happy to take your question on notice.

Senator KETTER: Are you familiar with the World Health Organisation report on this issue in relation to electronic nicotine delivery systems?

Dr Carpenter : I am familiar with electronic nicotine delivery systems and more generally with the report. I would have to refer to its contents specifically if you have specific questions in relation to the contents of that report.

Senator KETTER: Perhaps the status of the report. It is relatively recent from 2014. It seems to me to the lay person it is an authoritative position on this particular issue. Can you comment on what the standing is of that particular report?

Dr Carpenter : I am happy to comment more generally on the status of electronic nicotine delivery devices. The college is considering, at the moment, evidence in relation to what are, more colloquially, termed e-cigarettes. The college is committed to providing evidence based guidance to policymakers to protect and promote the public's health. With regard to this the college considers that the evidence regarding the safety of e-cigarettes is currently inconclusive. The college is considering all of the available evidence and is developing a policy statement at present with regard to e-cigarettes. We are concerned about the potential for e-cigarettes to represent a gateway of sorts to the uptake of tobacco smoking, in particular, by vulnerable populations, including minors. Beyond that, as I said, the college is preparing a position statement on that topic at the moment.

CHAIR: For clarification, what is the difference between the Royal Australasian College of Physicians and the Royal Australian College of General Practitioners?

Dr Carpenter : The Royal Australian College of General Practitioners is the professional body representing the majority of general practitioners in Australia who provide medical care to individuals and to groups, usually as the first point of care in the community. The Royal Australasian College of Physicians consists of more than 20,000 members in Australia and New Zealand. Our college is made up of eight divisions and chapters representing specialists who work, for example, as paediatricians, cardiologists, respiratory physicians, occupational and environmental medicine physicians and public health physicians, and in chapters including the chapter of addiction medicine and faculties of public health. With regard to the way in which medical care of individuals is constructed in the current financial arrangements of Medicare, for example, there is a gatekeeping function between the provision of medical services by general practitioners whereby a patient is often referred to see a specialist physician of the college when in the opinion of the general practitioner that patient would benefit from specialist advice, for example from a cardiologist. In order for that specialist physician to receive the specific Medicare item number from that consultation, there must be a valid referral from a general practitioner—otherwise that specialist cannot claim the particular Medicare item in relation to that specialist consultation.

CHAIR: This is not a major issue, but I am just curious: aren't there also colleges for some of these specialists? Is there a paediatricians' college, a cardiologists' college and so forth? Or are they part of your group?

Dr Carpenter : Certainly, there are societies. For example, the Australasian Society for Infectious Diseases is a professional body consisting of health professionals working in the prevention and care of infectious diseases; however, the body which accredits training and provides training for specialist physicians in infectious diseases is the Royal Australasian College of Physicians. So, in that case, in order for a doctor to qualify as an infectious disease physician recognised for the provision of services as an infectious disease physician, they must complete training and pass exams set by the Royal Australasian College of Physicians. Does that answer your question?

CHAIR: Are there any other specialities where the college sets the standards?

Dr Carpenter : Yes. In the Royal Australasian College of Physicians, the adult medicine division sets training for basic medical training in adult internal medicine, and once doctors who have completed that training pass an exam they may then enter specialist training in cardiology, gastroenterology, respiratory medicine, infectious diseases and so on, both in paediatric medicine and in adult medicine. So, yes, there are a number of—

CHAIR: It is an entry approval to go into those other fields, is it?

Dr Carpenter : Into those specialties, that is quite right.

CHAIR: I understand. On page 3 of your submission, in the third dot point there is a statement that says:

Many people, including children, have limited capacity to make informed healthy choices.

Could you tell me who those people are, apart from children?

Dr Carpenter : I think there is public health evidence to support the role of additional factors which contribute to the ability of individuals to make informed choices.

CHAIR: No, that is an answer to a different question. Leaving out the children bit, your statement is:

Many people … have limited capacity to make informed healthy choices.

Who are those many people?

Dr Carpenter : I can speak in general terms as to disadvantaged groups in society who, on the basis of public health evidence, are more likely to suffer harm and be at a disadvantage, in terms of their health behaviours and health outcomes. I think it would be a pejorative of me to identify, on the basis of personal characteristics, individuals who would then necessarily be unable to make healthy choices. That relates to the nature of public health evidence, in my opinion, whereby it is very difficult to say that an individual will—as a result of particular personal, socioeconomic, cultural and health characteristics—have difficulty making informed healthy choices. Certainly, there is a significant body of evidence to show the population risks relating to people with certain health characteristics.

CHAIR: The obvious implication in that statement is that some people have greater capacity to make informed healthy choice on behalf of those people who have limited capacity. Would you agree?

Dr Carpenter : I would agree that across the population we are all different in our capacity to understand and interpret a full range of information, for example financial information, occupational information, economic information and so on and so forth. I think that in relation to our ability to judge and make healthy behaviours—what is often termed 'health literacy'—there is good evidence to support the notion that people do have inherently different abilities to judge and make choices in relation to their own health.

CHAIR: Do you think anybody could make better decisions about your health than you?

Dr Carpenter : I do not think it is a question of whether another body or individual can make choices in relation to an individual's health better than them. It is more a question of the extra-individual or extracorporeal influences on an individual's health. The Royal Australasian College of Physicians is committed to providing evidence based information to guide policy in this respect. We note that across a large range of studies, and across a large range of health topics, the influence of environmental, occupational, social, economic and cultural factors on the health of individuals is undisputed. It is our position that those factors are important contributors to the health of individuals.

CHAIR: I am still curious about these people who have limited capacity to make informed healthy choices and how that is to be remedied. The obvious implication is that there are people who have superior capacity to make informed healthy choices. The inference from that statement would suggest that they should, in fact, be the ones who make the choices for those who have limited capacity to make informed healthy choices. Is that a reasonable inference from your statement?

Dr Carpenter : No. That was certainly not our intention—

CHAIR: That is not your intention?

Dr Carpenter : That was not the intention of that statement. I would not agree with that inference. The basis on which public health physicians and members of the college develop evidence is to study the population level associations with the individual's health, including their health literacy and ability to make informed health choices for themselves. We recognise, on the basis of that evidence, that there are a broad range of factors which contribute to the health of individuals.

CHAIR: I am curious to understand what your intention was in the first dot point of your submission:

Individuals are not on a level playing field with industries that invest enormous amounts of time and money towards making unhealthy choices easier and more tempting …

What are those industries, and what are those unhealthy choices?

Dr Carpenter : According to the Australian Institute of Health and Welfare, 85 per cent of the burden of disease in Australia today, measured in terms of disability and adjusted life years, is due to non-communicable diseases such as heart disease, cancer, rheumatological diseases, chronic lung disease, and alcohol related and smoking disease. Obesity and being overweight are some of the leading contributors to the burden of disease in Australia. It is accepted and published by the Australian Institute of Health and Welfare that the vast majority of non-communicable diseases can be prevented. In terms of unhealthy choices, we know that the consumption of a diet which is high in energy-rich, low nutritional content food, getting an insufficient intake of fruit and vegetables as recommended by the CSIRO, having insufficient exercise and becoming overweight over time are health behaviours which unquestionably contribute to an increased risk of preventable non-communicable disease.

As to your question in relation to industries that invest amounts of money and time, I think it is certainly true of all industries which market products to Australian consumers that they have a legitimate business interest in marketing their products to Australian consumers. I do not think any member of the college would dispute the right and role of those industries to market those products and substances to Australians in accordance with the relevant law in the jurisdictions in which they operate. From a public health point of view, our concern is in relation to unhealthy lifestyle risks and health behaviours which can adversely impact the health of individuals and populations over time. In that respect, we are conscious that individuals have a limited ability to process complex information. We know that once human beings are confronted with a very complex set of information they have a limited capacity to process that information and make rational choices, and we are interested in supporting access to healthy lifestyles, healthy food and healthy environments to protect and promote the health of individuals in Australia.

CHAIR: Yes, but you have not answered my question. What are those industries that make it easier, as you said—and more tempting—to make unhealthy choices?

Dr Carpenter : The college is concerned about the health risks to Australians in relation to prevalent causes of preventable disease in Australia. Certainly leading causes of preventable ill health in Australia include obesity, lack of exercise, consumption of tobacco and excessive consumption of alcohol. By no means do we wish to represent our position as wishing to interfere with the consumption, in moderation, of foodstuffs and beverages that have been shown to be of no harm to individuals' health. But we know there is clear-cut evidence of the burden to individuals, communities and the Australian health system from, for example, excessive consumption of alcohol and tobacco, and that has been proven over many decades and through multiple lines of evidence.

CHAIR: You are still not answering my question. Which industries invest enormous amounts of time and money to make it easier to make unhealthy choices?

Dr Carpenter : The college, for example, has released a position paper, which I am happy to table—

CHAIR: Tell us what is in it.

Dr Carpenter : in relation to alcohol. The college's alcohol policy was released in March 2016 and is titled 'The Royal Australasian College of Physicians and the Royal Australasian and New Zealand College of Psychiatrists Alcohol Policy March 2016', and the college's brief of evidence in relation to alcohol promotion in sport is titled Through children's eyes: alcohol promotion in sport, and I am happy to table those documents.

CHAIR: This inquiry today is mainly around smoking and e-cigarettes, so we might not worry about that right now, thank you.

Dr Carpenter : Certainly the college would consider that the advertising of alcohol and cigarette products to vulnerable populations, including minors, is a key concern for the health of Australians, and we would strongly support appropriate regulation to limit advertising of those products to minors through sporting and other events in Australia and through television advertising.

CHAIR: We want to get on to the specific topic that is being discussed today. You have cited the Nuffield Council on Bioethics and its monograph from 2007, Public health: ethical issues, in your submission, and you rely on it to a reasonable extent. It has been cited by other people who have an interest in public health as well. It has also been influential, if you like, in the UK. Nuffield's intervention ladder and its other recommendations have been referred to by both the UK and Australia. The thing is, they have come to different conclusions.

Dr Carpenter : Sorry—when you refer to 'they'—

CHAIR: Australia and the UK, in policy terms—

Dr Carpenter : Governments of Australia and the UK?

CHAIR: Governments, yes, and also public health organisations in the two countries have come to different conclusions. In the UK, for example, there has been Public Health England's rather substantial report on e-cigarettes. They also have a different approach to the sale and service of alcohol and a different attitude to the use of bicycle helmets than in Australia. That is three from six of the terms of reference of this inquiry. Australia has virtual prohibition of e-cigarettes and substantially tighter regulations on the sale and service of alcohol and also is one of the few countries in the world that requires obligatory bicycle helmets. Yet they both ostensibly draw from Nuffield's work. How do you think this distinction has arisen?

Dr Carpenter : I could not comment on the specific reasons the different regulatory outcomes have arisen in the two different health systems. I certainly acknowledge that there are different regulatory approaches to these important health topics in both countries. But, again, I could not comment as to the specifics of why they have arisen. I would be happy to comment on the evidence base and what the college's position is in relation to those health topics.

CHAIR: Your submission expresses concerns that the introduction of e-cigarette regulations do not re-normalise smoking behaviour. That is on page 6 of your submission. I do not think anybody would disagree with that. This is a concern you have raised. Do you think that is a real and present risk involved in e-cigarettes?

Dr Carpenter : The college considers that the evidence is not conclusive yet to enable an evidence based determination to be made about whether e-cigarettes represent a definite gateway to tobacco smoking, in particular by minors. I am certainly aware of Public Health England's report in relation to e-cigarettes.

CHAIR: You are aware of that? They did not think there was a risk?

Dr Carpenter : It is my understanding that they have concluded not that there is not a risk; they consider that on balance e-cigarettes may be safer on a population level. It is my understanding that the safety of e-cigarettes depends very much on the content of those e-cigarettes. The college is certainly considering the safety of e-cigarettes and its role in harm minimisation in relation to tobacco smoking in Australia.

CHAIR: So, it is considering its position. You do not have, to use a contemporary term, a landing point on that yet?

Dr Carpenter : The college is drafting a policy and position statement in relation to e-cigarettes at the moment, and it is considering the evidence in relation to e-cigarettes. The college is committed to reducing the harms of tobacco smoking in Australia. The college and particularly the Faculty of Public Health Medicine recognises the role of harm minimisation, where abstinence from harmful products may not be possible and is certainly investigating what role, if any, e-cigarettes may play in preventing harm, in particular through continued exposure to tobacco smoking.

CHAIR: So at the moment your policy is under review.

Dr Carpenter : It is being drafted at the moment.

CHAIR: All right. I am not going to be able to get you to commit a college view on this at the moment.

Dr Carpenter : And not because I do not wish to be constructive to the Senate's legitimate inquiry into the role of e-cigarettes in public health in Australia. On the contrary, it is the college's desire to ensure that we contribute rigorous, evidence based advice to guide policy making. And because we do not feel that we have a position to support that yet, I am unable to comment further.

CHAIR: Public Health England has said, in its report, that there is a 95 per cent reduction in harm—risk—achieved by replacing tobacco with e-cigarettes, and the 95 per cent is a composite of a number of factors that they have taken into account. It is considered to be a highly qualified and authoritative study. The arguments that were presented to us earlier today are along the following lines. If smokers simply cannot bear to quit—and after all these years I think that is probably a safe assumption—then harm reduction, as you have indicated, is a legitimate approach. So is the only issue, from your college's point of view—whether or not you accept that it is 95 per cent less harmful—whether it is substantial?

Dr Carpenter : I think there are a number of questions. We are certainly considering evidence from other jurisdictions in relation to e-cigarettes and their role in harm minimisation as well as the role of e-cigarettes and marketing by companies who may seek to use e-cigarettes as a vehicle to normalise smoking behaviours and encourage uptake of tobacco smoking. So the college is considering not only evidence from jurisdictions such as the United Kingdom but other evidence to ensure that we make an evidence based recommendation using all available evidence, including any evidence of risk of harm through the adoption of e-cigarettes by individuals.

CHAIR: Public Health England, I agree, is not the only source of evidence on this issue. You have referred to two other sources in your submission, which are in the US and Poland. We asked a couple of witnesses earlier today about those. You have stated as a fact that uptake amongst adolescents who had never previously smoked has more than tripled. They disputed that. In the case of the United States, the suggestion was that adolescents had experimented at a higher level but had not actually taken up consumption of e-cigarettes on an ongoing basis. That correlates, also, with Public Health England's observation that teenagers of any description try things, but there has been no ongoing uptake. In fact, Public Health England's view is that the number of people using e-cigarettes who have never smoked before is tiny. That is their view. Is there anything about that that you disagree with?

Dr Carpenter : The evaluation of that evidence, including those published studies and evidence accumulated in other jurisdictions, is exactly the reason why the college wishes to incorporate all available evidence to reach an evidence based policy position. We have not yet had the opportunity to review all the available evidence. We have noted, as you point out in references 30 and 31 in our submission on page 7, the potential for risk due to the use of e-cigarettes by adolescents in at least two other jurisdictions.

CHAIR: Earlier witnesses have said that that is not what those references are indicating.

Dr Carpenter : I understand.

CHAIR: I am not taking a view myself.

Dr Carpenter : And I am obviously not privy to the earlier testimony. But it is the evaluation of those references and other evidence which the college is currently undertaking, and we use that by way of example to demonstrate why we have concerns about e-cigarettes and that we wish to consider all of the available evidence to reach an evidence based policy position.

CHAIR: When do you think the college will have considered all of this and have a position?

Dr Carpenter : I am sorry, I would have to refer to the lead fellow in charge of that policy position and take that question on notice.

CHAIR: All right. If I can just go further, in your submission you talk more broadly in the context of vaccination rates. The college writes:

The RACP believes that a punitive approach to policy, such as restricting access to other social benefits for unimmunised children and their families, is not the most effective way of increasing immunisation uptake. Instead we favour an evidence-based approach to policies to improve the vaccine-uptake rate.

In the case of vaccines, you are not in favour of the government's current policy of restricting access to childcare rebates for unimmunised children. Is that correct?

Dr Carpenter : The college supports universal vaccination of children to prevent communicable diseases. I will come directly to your question: vaccination has been perhaps the single greatest achievement in the Australian healthcare system in the 19th and early 20th century. It has reduced the incidence, morbidity and mortality of communicable diseases to a highly significant level.

Fellows of the college have been instrumental in the research and development of vaccines, as has the government's creation and promotion of the Australian Childhood Immunisation Register to prevent the scourge of communicable diseases which are still prevalent in other jurisdictions around the world. We are incredibly lucky to have such an effective Australian childhood immunisation scheme.

In regard to approaches to improving vaccination rates in Australia, the college believes that punishing socioeconomically vulnerable populations for not vaccinating their children has the risk of potential health harms. We would prefer to see other policies which promote vaccinations through communication strategies that take account of, for example, disadvantaged groups who are culturally and linguistically diverse or socioeconomically disadvantaged, based on public health evidence, as opposed to financially punitive policies which affect the most socioeconomically disadvantaged groups in Australia.

CHAIR: That is interesting because you have previously said in your submission that you favour financial incentives—

Dr Carpenter : Could you point out where and I would be happy to refer to it.

CHAIR: Page 3, the paragraph under the dot points:

Measures, such as tobacco and alcohol taxes, ensure individual consumers bear some of the cost to government and are financially motivated towards limiting risky behaviour.

There is a financial incentive to have your kid vaccinated and you are opposed to that.

Dr Carpenter : We think that there are alternative policies which would be less punitive. Therein lies a distinction between positive and punitive financial incentives and I think economists would certainly—

CHAIR: If it is money going into your pocket or out of your pocket that is a similar sort of thing. The evidence we have heard this morning suggests that those people who are paying the heaviest penalty for continuing to smoke cigarettes are those who are the most disadvantaged in society. The highest rates of smoking are in the lowest socioeconomic groups—the most vulnerable groups.

We had evidence this morning of figures ranging from in the 80 percentages—which somebody disputed, saying that it was too low—for prisoners, consumers of illicit drugs, coming down to Indigenous, low income people and so forth. In other words, the lowest socioeconomic groups are still the ones who continue to smoke. They are paying for this disincentive to smoke and you are in favour of that but you are not in favour of financial penalty to encourage parents to have their children vaccinated.

Dr Carpenter : I think they are fundamentally different public health issues. On the one hand you have a substance whose smoke has 43 known different carcinogens, with very strong evidence of harm to individuals—that there is no safe level of smoking. I certainly agree that the prevalence of smoking is higher among socioeconomically disadvantaged populations and therefore flat consumption taxes, for example tobacco taxes, disproportionately affect more socioeconomically disadvantaged groups. I think that is a matter of economics and mathematics. There is no question of that.

I think that is a different financial issue because it is providing a disincentive for a harmful health behaviour—in this case, consumption through inhalation of a known carcinogen—versus punitive incentives for not vaccinating a child. I agree they are both financial incentives—of course, that is obvious—but in this case regarding vaccination that is a positive health behaviour with very large health benefits and the college is concerned that punitive measures in restricting access to welfare benefits by families eligible for family tax benefit part A who do not vaccinate their children in a timely way, for example, may dissuade them from engaging with healthcare providers in the future or may have adverse health consequences for those individuals. We would favour alternative evidence-based policies to improving vaccination rates in Australia.

CHAIR: In the case of cigarettes and e-cigarettes the logic would be that, if the Public Health England's assessment of e-cigarettes is that they represent 95 per cent reduction in harm compared to tobacco, then you would support the cost of e-cigarettes being 95 per cent lower than the cost of cigarettes; would you?

Dr Carpenter : No. I think they are separate issues. I am not sure there is a logical nexus between financial incentives not to smoke and proposing a subsidy for the cost of e-cigarettes.

CHAIR: No-one is talking about a subsidy.

Dr Carpenter : I am sorry. I may have misunderstood when you said that there would be a 95 per cent lower cost of e-cigarettes. I may have misinterpreted that.

CHAIR: That may just be a consequence of the government's tax policy. It may just be levying a lower level of tax on e-cigarettes than it does on tobacco. So the end result is that a consumer has a choice between an e-cigarette and a tobacco cigarette and the cost of the e-cigarette is 95 per cent lower.

Dr Carpenter : Again, because the college is still determining its position on e-cigarettes—

CHAIR: You are not in a position to say.

Dr Carpenter : We absolutely support the role of harm minimisation. Fellows of the Faculty of Public Health Medicine, for example, are actively involved in the medically supervised injection centre in Sydney for the harm minimisation of injecting drug use—

CHAIR: So the college supports that?

Dr Carpenter : We do not support injecting drug use; we support harm minimisation, and there is evidence that—

CHAIR: Managed at the injection room?

Dr Carpenter : We support strategies to reduce the harm of injecting drug use in Australia. Australia's official drug policy has been harm minimisation for some two decades now. I note that the current government has recently agreed to subsidise the cost of treatment for hepatitis C in this country. Because of the burden of hepatitis C in this country—with an estimated more than 230,000 people infected with chronic hepatitis C—there are enormous personal, social and economic costs to the community. The college was very pleased to see the government supporting PBS funding of therapy to eradicate hepatitis C from Australia. We would like to see this and other strategies to eradicate hepatitis C and other communicable diseases from Australia.

CHAIR: What is its view on the safe injecting rooms though?

Dr Carpenter : I cannot speak as to the official—

CHAIR: You do not know?

Dr Carpenter : It is not that I do not know; it is I cannot speak as to the position. I would have to confer and take your question on notice.

CHAIR: I do not want to put you on the spot on any more issues.

Dr Carpenter : I am happy to answer more questions.

CHAIR: Thank you very much, Dr Carpenter. That concludes today's hearing. I thank all the witnesses who have appeared.

Subcommittee adjourned at 14:29