22 December 2015

Public Health Messages

The Tasmanian Health Minister has sent a brave and positive public health message through a proposal to raise the minimum legal smoking age to 21 or even 25.

The Minister announced "an ambitious goal for Tasmania to have the healthiest population in Australia by 2025", commenting
Addressing Tasmania’s high rates of chronic disease and health and risk factors such as smoking, obesity, poor nutrition, low physical activity levels and risky alcohol consumption is a priority of our draft Consultative Healthy Tasmania Five Year Strategic Plan
The announcement states
The Consultation Draft outlines that smoking and obesity will be priorities under the first five year strategic plan. This is where evidence tells us we can make a significant change in population health outcomes.
The Government has included ideas on improving nutrition and access to healthy food, improving physical activity and recreational infrastructure, developing community-led action plans and taking a ‘life stages’ approach of developing healthy habits in kids and supporting older people to remain healthy and independent.
The Consultation Draft also proposes raising the minimum legal smoking age. Current laws make it illegal to smoke under the age of 18; but there would be significant health benefits associated with raising the legal age to 21 or 25.
International evidence supports raising the minimum legal smoking age as a means of targeting the most at-risk age category for smoking uptake. Studies show that most smokers take up the habit before the age of 25. There would likely be significant health benefits for the community and savings to the health system over time if the rate of people taking up smoking was reduced. 
The draft Plan [PDF] indicates
Potential Future Initiatives To Target Smoking
Tobacco smoking is one of the most serious public health challenges we continue to face as a society, despite substantial progress in recent decades. The Government is committed to thinking boldly about how we can better address this challenge.
The Tasmanian Government sees a clear need to target the smoke free message and related programs if we are going to significantly reduce rates of smoking.
The focus should be on reducing uptake of smoking amongst young people, smoking during pregnancy and reducing smoking rates. This is also an active agenda for QUIT Tasmania at the Cancer Council, the Heart Foundation Tasmania, PHT and the Tobacco Control Coalition. Earlier in 2015, the Government commissioned a Discussion Paper, Options for a Public Health Response to e-Cigarettes. A report has been prepared for the Tasmanian Government based on that feedback, which will be considered as part of development of the final Healthy Tasmania Strategic Plan.
Current smoking statistics
The National Drug Strategy Household Survey 2013, in comparing smoking rates of differing age groups based on self-reported data, found that 3.4 per cent of 12-17 year olds in Australia are daily smokers. Amongst 18-24 year olds, 13.4 per cent reported themselves to be daily smokers. This represents a 10 per cent increase – the largest increase between successive groups across the entire age spectrum.
Tasmania’s statistics are stark - in 2011-12, over 30 per cent of young Tasmanians aged 18-24 years were current (daily or occasional) tobacco smokers, compared with about 7 per cent of older Tasmanians aged 65 years and over. Further, in 2013, 15.1 per cent of all mothers and 33.4 percent of teenage mothers smoked. Only 1.5 per cent of women who reported smoking during the first 20 weeks of pregnancy did not report smoking during the second 20 weeks.
Tobacco smoking is recognised as one of the largest preventable causes of death and disease in Australia. In 2004-2005, smoking was estimated to cost the country around $31.5 billion in social and economic costs, including to the health care system. During the same period, smoking resulted in over 750,000 days spent in hospital and $670 million in hospital costs
Smoke-free generation
The Hon. Ivan Dean MLC first tabled the Public Health Amendment (Tobacco Free Generation) Bill in late 2014 in the Legislative Council. This has led the way on innovative thinking about how to better address the challenge of reducing smoking rates. The Government commends the intention of that Bill, as any initiative aimed at reducing smoking rates is laudable. However, the Government has consistently held concerns about its complexity and likely efficacy, which has prompted bold thinking about how we could achieve significant reductions in smoking rates in a practical, less complex way.
Potential Future Initiative No 6:
Smoking cessation in pregnancy improves the health of the unborn child. A Non-Government Organisation partners with a Primary Health Network and the Tasmanian Health Service on a program to reduce smoking rates in pregnancy. ccccccc The program identifies all women who are smoking at the diagnosis of the pregnancy and provides brief intervention in general practice, strengthens smoking cessation skills in doctors and midwives in antenatal clinics, and uses the patient information management system to ensure that clinical guidelines regarding smoking cessation in pregnancy are systematically implemented.
Such nudging is unlikely to attract major criticism. There will be more debate about raising the smoking age -
Potential Future Initiative No 7: Raising the Minimum Legal Smoking Age
Extending the Minimum Legal Smoking Age (MLSA) beyond 18 through amendment to the Public Health Act 1997 could provide an opportunity to enact some far-reaching change. While it would be a national first, there is international research and practical evidence to support that increasing the smoking age and preventing uptake of smoking can lead to significant reductions in smoking rates with positive life-time effects.
Evidence for raising the MLSA
In 2015, the US Institute of Medicine (IoM) released an extensive report investigating the likely efficacy of increasing the national MLSA. The study reported that approximately 90 per cent of adult daily smokers in the US reported their first use of cigarettes before reaching 19 years of age, while almost 100 percent begin before the age of 25. It used mathematical modelling to estimate the relative effect of raising the MLSA from 18 to 19, 21 or 25.
The researchers concluded that if the MLSA were raised now, by the time today’s teenagers reached adulthood, within that cohort there would be a 3 per cent overall reduction in smoking prevalence if the MLSA were raised to 19, a 12 per cent overall reduction in smoking prevalence if raised to 21 and a 16 per cent overall reduction in smoking prevalence if raised to 25. These benefits would presumably carry through over time as a greater proportion of the population had been subject to such a law.
In 2015, Hawaii became the first US state to pass legislation to raise the MLSA to 21, which will take effect from 1 January 2016. Similar debates have recently been taking place at the state level in Washington and California.
While it may take some time before the full impact on smoking rates in Hawaii is able to be measured, a number of other US municipalities and counties have also raised the MLSA to 21, including New York City. The first city to do so was Needham, Massachusetts in 2005. Data from Needham showed that following this, tobacco use among high school students was reduced almost by half, and the rate of frequent tobacco use fell by 62 per cent – significantly faster than surrounding areas.
In the IoM study, one of the models used projected that if the MSLA were raised to 21 across the United States, there would be approximately 223,000 fewer premature deaths, 50,000 fewer deaths from lung cancer and 4.2 million fewer years of life lost for those born between 2000 and 2019.
Practical considerations
Any move to increase the MLSA in Tasmania would need to consider how to treat those within the relevant age cohort who are currently legally able to smoke at present, as well as those currently underage but who will attain majority before any change came into effect. One option would be to enact transitional arrangements for a defined period in order to promote and socialise new arrangements. However, the extent to which any agreed increase to the MLSA is delayed would represent continued increased risk of smoking addiction to the relevant age cohort.
There is also the matter of how such a law should treat international and interstate tourists coming to Tasmania under a higher MLSA. We need to consider whether tourists should be required to observe Tasmanian laws, as is the case with other laws which differ from other jurisdictions, or whether they might be exempted for purchasing and/or possession and use.
There is also the matter of what impact such a law may have on retailers. We can assume that there may be an initial modest impact on retail trade, which could increase over time with progressive decreases in overall smoking rates. Having a transitional or ‘phase-in’ period may have the added benefit of allowing businesses time to model and adjust for any anticipated impact on trade.
The draft accordingly asks several questions
Do you support increasing the minimum legal smoking age to 21? If so, do you support a phase- in arrangement with respect to those currently legally able to smoke in the 18-20 age cohort?
Do you support increasing the minimum legal smoking age to 21, and subsequently increasing it to 25 later, based on evidence of impact?
Do you support increasing the minimum legal smoking age to 25? If so, do you support a phase-in arrangement with respect to those currently legally able to smoke in the 18-24 age cohort?
What impact would there be on tourists and visitors to the State in increasing the minimum legal smoking age and how could these be alleviated?
Do you support maintaining the status quo? If so, what are the reasons?