Title Standing Committee on Health, Aged Care and Sport
05/10/2017
Use and marketing of electronic cigarettes and personal vaporisers in Australia
Database House Committees
Date 05-10-2017
Source House of Reps
Parl No. 45
Committee Name Standing Committee on Health, Aged Care and Sport
Page 14
Questioner CHAIR
Wilson, Tim, MP
Zappia, Tony, MP
Responder Mr Moore
Ms Dalla
Prof. Moore
System Id committees/commrep/33958043-2bc7-4da3-b695-c5cecef079e3/0003


Standing Committee on Health, Aged Care and Sport - 05/10/2017 - Use and marketing of electronic cigarettes and personal vaporisers in Australia

MOORE, Mr Michael, Chief Executive Officer, Public Health Association of Australia

DALLA, Ms Danielle, Policy and Communications Manager, Public Health Association of Australia

[10:36]

CHAIR: Welcome. Does either of you have any objection to being recorded by the media today?

Mr Moore : No objection.

Ms Dalla : No objection.

CHAIR: I remind witnesses that these hearings are formal proceedings of the parliament and the giving of false or misleading evidence is a serious matter and may be regarded as a contempt of the parliament. The evidence given today will be recorded by Hansard and attracts parliamentary privilege. Did either of you wish to provide further information about yourself or the capacity in which you are giving evidence today?

Mr Moore : I am an adjunct professor at the University of Canberra, a visiting professor at the University to Technology, Sydney, and I am appearing today as both CEO of the Public Health Association of Australia and the president of the World Federation of Public Health Associations.

CHAIR: Would you like to make an opening statement?

Mr Moore : I will make a brief opening statement and focus really on the particular area we would like to focus on, although I do have to say that, by and large, our organisations agree with what has been said by the two previous witnesses. I would like to add that we have exactly the same attitude to being in the committee with big tobacco. I won't repeat the language they have used.

CHAIR: With the Association of Convenience Stores being here?

Mr Moore : Just big tobacco. I would like to quote from the abstract of an article I had published in the American Journal of Public Health Policy:

Some supporters of electronic cigarettes have argued that they should be considered a form of harm reduction, analogous to that which has been successful with narcotics. In this viewpoint, my co-authors and I contend that this argument is based on highly selective use of the evidence, coupled with a fundamental misunderstanding of a comprehensive harm minimisation strategy. This includes not only harm reduction but also reduction in demand and supply—two elements that are explicitly rejected by many advocates of electronic cigarettes. We contend that, in the absence of all three elements, there is a danger that electronic cigarettes will delay the achievement of a tobacco-free world.

Beyond that, I would add that my perspective is that big tobacco is attempting to reframe the electronic cigarette issue as a health issue firstly, and they are also attempting to redefine what we mean by a tobacco-free world. In doing this, I think we are in the position of creating much more harm than we might otherwise achieve. However, I am very comfortable about discussing a harm-minimisation approach, and particularly the harm-minimisation approach that has just been reconfirmed by the Australian federal government and all states and territories in the National Drug Strategy, only a month or so ago.

Finally, compared to other nations, Australia is different: Australia has achieved huge success in reducing tobacco use. One of the key elements to keep in mind is that, when we look at our 12- to 17-year-olds, we see that two per cent of people are taking up tobacco. We do not want to see any form of tobacco re-normalised.

Secondly, although we talk about 12 per cent of Australians smoking, in the ACT, where I live, it is in the order of 10 per cent, which we're very proud of, but, even more importantly, in North Sydney down to the beaches area—Manly and so forth—around seven per cent of people on tobacco users. So I think what we have is quite a different situation than in other parts of the world. I'm very happy to take any questions on this or anything in our submission, but I assume that you have our submission and it can be read.

Mr TIM WILSON: Starting with the comments you just made about smoking rates, perhaps you could inform the committee how that data is collected. Is it based on general survey data or is it based on purchasing behaviour of people in age brackets?

Prof. Moore : The figures that we quote are usually from the Australian Institute of Health and Welfare, and we're very comfortable that the Australian Institute of Health and Welfare, in collecting its information and doing its assessment, does so on a rational and reasonable scientific basis, and we have faith. I am not in a position to specifically answer your question as to the detail of that style of research.

Mr TIM WILSON: Thank you, but I'll go back and investigate it because I'm curious. I guess I only have one real question, unless you have some observations on earlier questions which because you've sat through the previous proceedings you want to include; otherwise there is no point repeating them. I presume, based on the approaches other witnesses have brought, you have brought a very similar one that you probably share—though I'm not trying to verbal you with their perspective. How much do you think the absence of a harm reduction strategy for, for instance, illicit products and illicit drugs is driven by the access to substitutable products that people can go from them to? Has that existed in the same way with tobacco? Obviously, we have nicotine replacement therapies, which create substitution options. Can this be part of that process as well?

Prof. Moore : I came into public health through my work on illicit drugs, so I do have quite a reasonable understanding of that, and I see some really significant differences with regard to this. First of all, when we are talking about tobacco as a legal product, the work of Emily Banks at the ANU illustrated the level of harm of tobacco. Two-thirds of people who smoke tobacco will live 10 years less. That's just the mortality side; she also has done work on morbidity. So, when I hear people talking about harm reduction with regard to e-cigarettes—the figures are accurate; now I'm making a hypothesis—are they proposing that we say, 'If e-cigarettes mean that half of people die five years younger, that's a good thing'? It's actually a bad thing. So, in reframing the argument, somehow or another we get this idea that we're going to be saving lives if we go down this path of e-cigarettes or—let me be really specific—wide availability of e-cigarettes. To come back to your question of how this relates to the way we deal with illicit drugs, I heard questions around heroin and methadone, for example—

Mr TIM WILSON: The key part of my question is around substitution.

Prof. Moore : The difference between the illicit drugs and this situation is that we're talking about illicit drugs that are controlled underground by criminal syndicates, where we need to have really quite specific measures. The really interesting thing about the Australian drug strategy is that it doesn't just apply to illicit drugs. The tools that it provides go right across the spectrum of the drugs that we use, and they are, by and large, about controlled availability.

When we talk about harm minimisation, I hear people confusing harm minimisation and harm reduction. The overall policy is harm minimisation, of which harm reduction is one part, but it only minimises the harm if it's done with supply reduction and demand reduction. So you need to have the appropriate policing—for example, we were talking about nicotine and e-cigarettes being brought in illicitly—as we do with tobacco, as we do with cannabis and ice. And we need demand reduction, which is largely about the appropriate treatment. In this case, with e-cigarettes, to what extent are they being used as a treatment? Within the context of that, with a product that is not illegal, we need to be saying, 'What is the most effective way to control it?' and that's where we are in exactly the same frame of mind as the previous people who spoke to you—that this is something that the Therapeutic Goods Administration should be dealing with. If big tobacco companies really think these products are appropriate and should be brought into Australia—and this is not just about the nicotine but about the 4,500 flavours in the pictures in our submission and the 7,000 or so flavours that are now I think available in the United States—that has to be taken into account by the TGA in terms of an appropriate regulation.

CHAIR: I was going to ask whether you've had a chance to look at the approach that New Zealand is taking in relation to the regulation of e-cigarettes and whether you had any comments about that.

Mr Moore : I had a very brief discussion on Monday when I was in New Zealand with my colleague in the Public Health Association of New Zealand, but I have not gone into the detail of what they have done. One of the things raised in the discussion we had was how out of step England is with basically all public health associations around the world. I am now speaking with my hat on as president of the World Federation of Public Health Associations. We have an almost consistent statement with the Public Health Association of Australia. We kept the statements consistent deliberately. Basically what we are talking about now in my language is a system of controlled availability, and that controlled availability in the case of something legal like this has to have, first of all, those three pillars. Secondly, it has to go through the appropriate processes. In Australia, that's the TGA.

CHAIR: Do you agree that it's odd that a GP can prescribe e-cigarettes effectively as a cessation device, but you then have to go overseas to source the nicotine if you're the consumer? Do you think it would be more sensible and have better outcomes if the product were being provided and regulated onshore rather than people buying it over the internet with a prescription?

Mr Moore : Absolutely. That's why we would need to go through the TGA, to ensure that the regulation would be done in an entirely appropriate way, consistent with pretty well everything else that a GP prescribes. That having been said, I did hear you argue that you have many pieces of evidence from long-term smokers who have been able to reduce their smoking and even quit. The strongest evidence is that the most effective way to quit tobacco is to go cold turkey. That is the strongest evidence. That having been said, I certainly know public health people who have used e-cigarettes to reduce their smoking, and I'm hoping that they will eventually reduce it to the extent that they are not using nicotine at all. But what we don't know is what is in the e-cigarettes.

The second part to it is that in epidemiology this what we would call first of all a case and secondly a case series, both of which we consider pretty low-level evidence, even with all those people who have written into you and said, 'We have given up.' But it is good evidence to say we should be doing a proper study, and those proper studies are starting to take place around the world. Actually the results are really equivocal. You know that from the submissions that have been put to you. You just can't draw a clear conclusion from good, solid evidence that this is a particularly helpful device. I heard Mr Wilson in particular talking about the importance—which I agree with—of relying on the evidence.

CHAIR: You're in the unique position of having been a minister and a legislator as well. I want to go to the point that Mr Wilson referred to about something I raised earlier. At what point do you say that the law is effectively unenforceable and it's therefore better to regulate? I'm not quite sure whether the law has changed in the ACT. Isn't there a fair analogy with what the ACT and SA have done in relation to marijuana, which is effectively saying, 'We think it's ridiculous that we're being asked to devote law enforcement priorities to the personal use of marijuana, so we're going to decriminalise it'?

Mr Moore : Let me put on the record that it was my legislation that decriminalised cannabis in the ACT, changing it from the criminal process, whereby somebody could be put in jail, lose access to travel to places like the United States and so on, to decriminalising cannabis to a $100 on-the-spot fine. That was clearly a harm minimisation method and a different way of regulating. So I'm very comfortable about applying exactly the same process. But it was that experience that framed for me the whole importance of the focus being to minimise the harm. When we take account the minimising of the harm, as we've put in our submission, we're talking about making sure that we don't re-establish a position where, in any way, smoking—and I'm using it broadly to include cigarettes and e-cigarettes—is normalised. That would be an increase of harm. We would need to look at the personal level where somebody is using tobacco and, perhaps, using a combination of tobacco and e-cigarettes, or using it to come off, and we see there a reduction in harm. So we need to look at the evidence in each of these.

The challenge for us in public health generally is that, invariably, ideas are put up—particularly by industry—and then we spend the next five years trying to do studies to show that what they are claiming is not accurate. In some ways, it's back to front. But that's the way the world works in many ways. So in this case I think what we need to keep in mind is looking at the evidence of: are we actually reducing the harm overall and what is the most effective way to regulate to reduce that harm? When you look at those pictures in our submission from Public Health England that I took myself when I was in Scarborough, there were three or four vape shops within about 100 metres of a tiny town all with a big 'come on'. They were clearly designed to attract young people. Let me add to that the one I saw on the internet recently with Thomas the Tank Engine, which I then pursued and did a bit of research on. Amongst vapers, Thomas the Tank Engine, apparently, is very popular. I'm not quite sure why they work that.

These are things that are about attracting young people into whatever form of smoking and normalising smoking. This has the potential to have a very significant increase in harm. So whatever the regulation is, it has to be extraordinarily tight. It's appropriate that it goes through TGA and it's appropriate that we have controlled availability. So to specifically answer Mr Wilson's question: yes, it is appropriate to regulate, but the regulations should be, I would say, tighter than tobacco. We don't put tobacco through TGA. All the rest of the regulation should be at least as tight as tobacco, such as with plain packaging, no smoking in restaurants and pubs and so forth—by the way, the issue which I was responsible for as a minister in the ACT. I would hate to see e-cigarettes suddenly now break through that and normalise any form of smoking in restaurants or pubs.

Mr TIM WILSON: May I extend a question on that? Say we went into an environment where it was made available, recognising the proposal that you've just suggested. What we would then have is a substitutable product. If multiple companies produced e-cigarettes and there was no capacity to, let's put it bluntly, product differentiate, which is basically what has happened to tobacco with the legacy brands, then the only capacity for them to compete would be, essentially, on price and accessibility. Are you concerned about that?

Mr Moore : I don't think it's true to say that the cigarette companies can't distinguish. They're allowed a 12-point description of their tobacco. What they can't do is the marketing—

Mr Tim Wilson interjecting—

Mr Moore : It's the marketing that is the key issue. I would argue that, in a system of controlled availability of a substance that we know will be dangerous—how dangerous it is is debatable, and you have the paper by Glantz and others that challenges that 95 per cent safety figure that came, really, out of nowhere. We are talking about a harmful substance. It should be regulated in exactly the same way as other things through the TGA, but the marketing should be extraordinarily limited.

Mr TIM WILSON: Sorry, I need to get to the point I was raising. With tobacco products, we had legacy brands, so we know what they are. They've been around, in many cases, for a very long time. They had previous advertising components to them, so people are able to product differentiate. Short of co-opting those brands, which may be what happens in the case of e-cigarettes, there would really be no way of differentiating, for the consumer, between the different options. It would be like a generic brand. One would mean nothing in particular if there were advertising and marketing restrictions associated with it, which we know would then lead them only to be able to compete, broadly speaking, on one basis, which would be price. Are you concerned about the consequences of that?

Mr Moore : If I were, I would also be concerned about the consequences of other health products that are prescribed—and, actually, very few of us know the difference between a range of codeines. I'm sure Dr Bartone does, but the rest of us don't. I think it's the same issue, that a restriction on—remember, the argument for these is that they are going to be a health product. If they're going to be a health product, then you have to treat them as that—or don't claim them as a health product. If it is being claimed that this is about helping people reduce or get off smoking—and the claim is both—then that's how we need to actually treat them. I think that—

CHAIR: Some people are arguing cessation; others are arguing substitution.

Mr Moore : That's why I said that. Substitution, too. I accept both arguments. Both would have a place, but both are a health argument. They are being framed as a health argument—

CHAIR: But one requiring TGA and the other not.

Mr Moore : They should both require TGA, even if you are talking about that, because we're still providing a substance through a controlled system for people to be able to use that substance to reduce their danger of tobacco smoking. It back to a health issue. That's how they've framed it.

Mr TIM WILSON: Let's throw out the health argument then. In a free society, all things are legal until things are explicitly made illegal or regulated and have regulated access. There is also a component of this debate which has to be about free choice. In that environment, are you concerned then about the capacity in which price can be used to drive down cost, which makes it more accessible because you create an interchangeable product?

Mr Moore : When we have competition, that's what we're going to see. First of all, a good government stewardship can regulate price. That's the first thing. What we've got is a choice between that freedom of choice and good government stewardship. That's what we apply, for example, right across road safety. Good government stewardship demands you wear seat belts. I think that it's therefore appropriate that we apply the same good government stewardship as we apply on alcohol—although we would argue we've got a long way to go—the same good government stewardship as we've applied on tobacco and the same good government stewardship as we've applied on clean water, sanitation and all of these other public health issues. That's the role of government. Of course there's free choice, and we have to protect that as well. Getting that balance right between that personal choice and that personal responsibility, and government responsibility and good government stewardship is, of course, a challenge that this committee's facing right now on these issues.

Mr ZAPPIA: Professor Moore, in your opening remarks, you referred to the rates of smoking throughout society—I think 10 per cent or thereabouts. Can you provide the committee with similar trends with respect to alcohol consumption and illicit drug consumption?

Mr Moore : Not off the top of my head. We happened to be at the Global Alcohol Policy Conference yesterday. Internationally, I think 61.2 per cent of the world doesn't drink alcohol. That was a really interesting figure to me. I'm not one of those 61.2 per cent, actually! Obviously, you're talking about Australia.

Mr ZAPPIA: Yes.

Mr Moore : We are happy to take that on notice and will get back to you with the figures around the issues you asked about: alcohol and illicit drugs. I have to tell you: we will rely on the Institute of Health and Welfare figures; we will rely on Australian Bureau of Statistics' figures.

Mr ZAPPIA: I appreciate that. I'm trying to ascertain whether there has been a trend away from cigarette smoking to other forms of recreational substance use, whether it's alcohol or, indeed, obesity rates, which relate to increased food consumption.

Mr Moore : I can answer that question to a certain extent. What we do know is that, particularly amongst young people, there has been a reduction in harmful alcohol use and there has been a serious reduction in tobacco use. On illicit drugs, I'm going to have to look at what the household survey on drugs says. It's better that I get back to you with the sound evidence.

Mr ZAPPIA: Whilst the time period is relatively short, since e-cigarettes have been legalised—I think they've been legalised—in the UK and the USA—

Mr Moore : They're certainly made available in the UK.

Mr ZAPPIA: have there been any emerging trends in the short period that you can provide for the committee?

Mr Moore : I'll come back with evidence. The answer is yes. I have read some evidence, but I need to look at it carefully rather than reflect. The evidence right around this issue is still equivocal. The danger is that I read the things that are of interest to support my position. I'm trying not to cherrypick. We need to see what the evidence shows on both sides as to whether this is working. My understanding is that Public Health England are arguing that there has been a reduction in smoking, but I don't know how that compares to the reduction of a combination of the two things. They use the figure that it's 95 per cent safer, which, as I said, Glantz and others have challenged, and it deserves to be challenged. Their arguments fit into that framework. We have to look carefully at that. I'll come back to you with that information.

Mr ZAPPIA: Lastly, we've heard comments about Western countries—the UK, the USA, New Zealand and so on. Do you have any information about what is happening in the non-Western countries with respect to e-cigarettes?

Mr Moore : More importantly, I think that even today Philip Morris argue that they're working towards a smoke-free world. It's simply a lie. The reason I argue it's a lie is that we know big tobacco right around the world are increasing their sales of tobacco in the developing world and are showing very little interest in e-cigarettes there because they know they can sell their killer product to people who have not got the educational and social wherewithal to be able to understand the full dangers of tobacco. They don't have restrictions on marketing and price controls that apply in Australia. With this in mind, one can't help asking the question: is this just a ruse to somehow to do a cross-marketing process for big tobacco to be able to continue selling their legal product?

Mr ZAPPIA: Thank you.

CHAIR: Mr Moore, thank you for your time today. You'll be provided with a Hansard transcript of today's proceedings. If there are any corrections that you would like to make, you can do that through the committee secretariat. You undertook to provide some additional information flowing from Mr Zappia's question, so, if at all possible, if you provide that by 19 October, that would be very useful.

Mr Moore : Thank you very much for the opportunity to appear.

CHAIR: Thank you for joining us today.

Proceedings suspended from 11:04 to 11:16