Tobacco Control Advocacy in Australia: Reflections on 30 Years of Progress

Tobacco Control Advocacy in Australia: Reflections on 30 Years of Progress

Article  in  Health Education & Behavior · July 2001

DOI: 10.1177/109019810102800303 · Source: PubMed

CITATIONS

107

READS

93 2 authors:

Some of the authors of this publication are also working on these related projects:

Dog bitesView project

Sun protection behaviour patternsView project Simon Chapman

The University of Sydney 640PUBLICATIONS   10,027CITATIONS   

SEE PROFILE

Melanie Wakefield Cancer Council Victoria 429PUBLICATIONS   12,879CITATIONS   

SEE PROFILE

All content following this page was uploaded by Simon Chapman on 06 November 2018.

The user has requested enhancement of the downloaded file.

Tobacco Control Advocacy in Australia:

Reflections on 30 Years of Progress

Simon Chapman, PhD Melanie Wakefield, PhD

Australia has one of the world’s most successful records on tobacco control. The role of public health advo- cacy in securing public and political support for tobacco control legislation and policy and program support is widely acknowledged and enshrined in World Health Organization policy documents yet is seldom the subject of analysis in the public health policy research literature. Australian public health advocates tend to not work in settings where evaluation and systematic planning are valued. However, their day-to-day strategies reveal con- siderable method and grounding in framing theory. The nature of media advocacy is explored, with differences between the conceptualization of routine “programmatic” public health interventions and the modus operandi of media advocacy highlighted. Two case studies on securing smoke-free indoor air and banning all tobacco advertising are used to illustrate advocacy strategies that have been used in Australia. Finally, the argument that advocacy should emanate from communities and be driven by them is considered.

Australia has one of the best organised, best financed, most politically savvy and well-con- nected anti-smoking movements in the world. They are aggressive and have been able to use the levers of power very effectively to propose and pass draconian legislation. . . . The impli- cations of Australian anti-smoking activity are significant outside Australia because Austra- lia is a seedbed for anti-smoking programs around the world.¹

In Australasia, I think everyone here will know that there we have perhaps the most virulent and nasty-edged anti-tobacco lobbies to be found anywhere in the world. There is nothing less than a battle raging in Australia and New Zealand, and all the guns are out, on both sides, and to mix metaphors, the industry has taken its gloves off a long time since. . . . They have seen it all down there, and there is more of that to come. It is a bear garden. It is a zoo, and aggression, political in-fighting, dirty tricks by the opposition, and all manner of hassle and public argument is a feature of the business in Australasia.²

—The tobacco industry, on Australian tobacco control

Australia ranks highly among nations in efforts to reduce the burden of tobacco-caused death and disease.³Between 1945 and 1997, adult male smoking preva-

Simon Chapman is a professor in the Department of Public Health and Community Medicine, University of Sydney, Australia, and associate director of the VicHealth Centre for Tobacco Control, Carlton, Australia.

Melanie Wakefield is the deputy director of the Centre for Behavioural Research in Cancer, Anti-Cancer Coun- cil of Victoria, Carlton, Australia.

Address reprint requests toSimon Chapman, Department of Public Health and Community Medicine, Univer- sity of Sydney, 2006, Australia; phone: 612 9351 5203; fax: 612 9351 4381; e-mail: Simonc@health.usyd.edu.au.

Health Education & Behavior, Vol. 28 (3): 274-289 (June 2001)

© 2001 by SOPHE 274

lence fell mostly continuously from 72% to 22%. Female rates have fallen less spectacu- larly, from a peak of 31% in 1983 so that they currently equal male rates.^4,5Annual adult per capita consumption fell 61% from 3.54 kg in 1961 to 1.37 kg in 1999, reflecting fall- ing smoking prevalence and reduced consumption.⁴While smoking prevalence shows a classic inverse socioeconomic gradient, the growing proportion of ex-smokers varies lit- tle across socioeconomic status, which indicates that cessation efforts have had an even impact across the population.⁶ An outstanding exception is Australia’s Aborigines, among whom smoking prevalence often exceeds 60%.⁷Male lung cancer rates have fallen substantially, while female rates have continued to rise.⁸

Antismoking sentiment has existed in Australia since the end of the 19th century,⁹but efforts to explain the rapidly declining tobacco use have generally pointed to mileposts since 1970, which marked the introduction of various tobacco control policies, laws, and prominent antismoking campaigns. As will be argued, such explanations tend to give lit- tle credit to the factors that caused these visible and recorded “events.” The advocacy that precedes the introduction of a law or the factors responsible for the evolving enthusiasm of a politician for tobacco control are seldom recorded, “counted,” or even considered in evaluative research. Yet when basic questions are asked, such as, “How did Australia manage to get tobacco advertising banned?” or “Why has tolerance of smoking in public indoor areas reduced so much?” any account of the process should place advocacy at cen- ter stage.

This article highlights achievements of tobacco control advocacy in Australia since the 1970s. Next, it examines the nature, modus operandi, and, in particular, differences between advocacy and the activities of the mainstream health promotion community, which, in Australia, is dominated by behavioral science and local community develop- ment approaches. Two case studies (on smoke-free indoor air and tobacco advertising) illustrate how advocacy “works,” its influence and its evaluation. Finally, the prescription that advocacy needs to involve “communities” is examined, with the conclusion that while community support has been important in sustaining tobacco control action in Aus- tralia, community groups have seldom led the action.

ACHIEVEMENTS

Since 1970, Australian tobacco control advocates have made significant gains in the following areas:

• Harm reduction. Australian advocates were among the first to arrange for the tar and nicotine content of cigarettes to be tested and to advocate for the potential sig- nificance of tobacco yield data for harm reduction.¹⁰This work can be seen as an early chapter in the evolution of recent international interest in harm minimization¹¹ and the international momentum for tobacco products to be regulated in ways that parallel food and drug regulation.

• Advertising bans. Australia was one of the first democracies to ban all tobacco advertising and sponsorship.¹²

• Pack warnings. Australia has among the world’s largest pack warnings and pio- neered research into warnings to have maximum impact on youth.¹³Plans to imple- ment these saw prolonged periods of fierce counterlobbying by the industry.

• Mass reach campaigns. In the late 1970s, Australia was one of the first nations to run mass-reach antismoking campaigns.^14-16These were sometimes attacked by the tobacco industry and removed by an industry-dominated, self-regulatory process.

• Civil disobedience. Australia was the first nation to experience widespread civil dis- obedience against the tobacco industry through a campaign in which health and community activists “graffitied” tobacco billboards.^17,18 This effort dramatically reframed tobacco advertising from something most would have seen as an unre- markable, normal part of the commercial environment into a phenomenon that focused community discourse about irresponsible industry and collusive govern- ment policy unwilling to restrain it.

• Smokeless tobacco. In 1986, the South Australian government became the first gov- ernment in the world to ban smokeless tobacco. This ban subsequently went national.⁴

• Small packs banned. In 1986, the South Australian government was the first in the world to ban small “kiddie” packs (< 20 sticks). Again, this ban subsequently went national.¹⁹

• Tax. Australia has a relatively high tobacco tax by international standards²⁰—there have been many episodes of intense industry lobbying to restrain further rises.

• Replacement of sponsorship. Victoria pioneered the use of a dedicated 5% rise in tobacco tax (hypothecation) to enable the buyout of tobacco sponsorships²¹—some- thing the international tobacco industry acknowledges “has to be stopped.”²²

• Clean indoor air. Australia has among the world’s highest rates of smoke-free workplaces²³ and domestic environments.²⁴ Smoking is banned on all public transport, and violations are uncommon. Most states have banned smoking in restaurants.

THE NATURE OF ADVOCACY

The contribution of advocacy to public health, like that of biostatistics, epidemiology, vector control, and its other subdisciplines, should be assessed as a strategy or a means and not as an end in itself. Like its fellow disciplines within health promotion, properly conducted advocacy rests on analytic precision drawn from both theoretical perspectives and empirical trial-and-error experience. While public health advocacy has been prac- ticed at least from the time of John Snow’s successful efforts to persuade London’s civic authorities to remove the handle from the Broad Street pump to stop cholera transmis- sion,²⁵only in recent years have efforts been made to codify the often diffuse practice into the semblance of a genuine discipline—with theoretical underpinnings, principles, and practice guidelines.^26-31Much of this derives from political science and activist move- ments outside the health domain³²and draws heavily on framing strategy.^33,34A modest but growing research literature on public health advocacy may be found at http://www.health.usyd.edu.au/resources/mchbib.html.

However, as most Australian public health advocates do not work within research or scholarly settings, few would ever reflect on the theory behind their day-to-day strategies or plan their work according to the sort of models found in health promotion textbooks.

World Health Organization and Ottawa Charter health promotion templates do not fea- ture large in their frames of reference. Typically, their approach to their work is instinctive

but, on post hoc analysis, sophisticated and instructive for others wanting to advocate successfully.

Upstream Goals

The goals of advocacy involve changing “upstream” influences on health rather than efforts focused on persuading individuals to change health-related behaviors.³⁵Upstream factors—to continue the river metaphor—reach and potentially influence the living, working, and decision-making environments of whole populations with changes that flow “downstream” on implementation. In tobacco control, upstream goals include the following:

• legislative or regulatory provisions that ensure implementation in areas such as

• product regulation,

• advertising and promotion,

• packaging and product information,

• retailer licensing and vending machine control,

• preventing sales to minors,

• mandating smoke-free indoor air;

• fiscal policy such as the adoption of high tobacco tax rates and the channeling of portions of this to tobacco control programs;

• resource allocation to public information campaigns and to underpin cessation sup- port (“quitting”) services;

• the deregulation of smoking cessation products such as nicotine replacement ther- apy to allow increased access via pharmacies; and

• encouragement of governments in litigation against the industry and supporting pri- vate litigants.

Contested Debates

Invariably, the goals of advocacy are contested actively or passively. This can mean that there are readily identifiable and often determined opponents of the changes being advocated or that people who can influence the implementation of proposed changes are not so much opposed to them as they are passively resistant to giving sufficient priority to an issue. In such situations, the task of advocacy becomes one of breaking down public and political inertia or apathy about an issue, rather than overcoming active opposition.

Since many of advocacy’s goals require political support, advocacy is unavoidably a political activity, and government employees cannot participate overtly. In Australia, this has made advocacy largely a spectator event for many health promotion workers because they are government employees. The first rule of politics has always been simply to

“be there,” meaning that failure to have a position or argument noticed in highly competi- tive environments where many issues jostle for political attention will ensure that the issue remains politically invisible. In contemporary mass society, “being there,” above all else, means having an issue covered extensively in the news media. There are few con- temporary examples of advances in public health law, regulation, or resource allocation where extensive advocacy has not played out in the news media. Having an issue covered widely and positively by the news media is a necessary but not sufficient precursor to the

creation of supportive public and political environments. A veteran political reporter for theWall Street Journalnoted that

well done investigative reporting produces public outrage (or policy maker outrage) that forces new regulations and laws or tougher enforcement of existing ones. Ten-thousand-watt klieg lights turned on a situation focuses the minds of policy makers very fast.

A former Australian health minister explained why the national research budget for pros- tate and testicular cancer was 87 times less than that for HIV/AIDS research:

But it isn’t fashionable, it’s not at all in the front pages, it’s not sexy to have testicular or pros- tate cancer so you don’t get a run. (P. 35)³⁷

News coverage can also work against political support if it frames a public health issue in ways that are incompatible with values that are compelling to political leaders. In a pro- tracted era of political liberalism and global market deregulation, tobacco control’s agenda of heavily regulating the tobacco industry requires the harnessing of particularly powerful values that can override broader free-market dogma. Efforts to position the tobacco industry as a pariah industry^38,39—undeserving of normal laissez-faire regula- tion—have been vital to the ever-widening policy of regulatory exceptionalism that char- acterizes the tobacco industry. Much advocacy essentially challenges radio and television audiences and newspaper readerships—including the politicians at whom it is often ulti- mately directed—to locate themselves in a moral debate and sometimes to declare pub- licly with which side of a debate they wish to be identified. Advocacy also implicitly frames problems as requiring solutions, and politicians frequently are cast as those responsible for finding those solutions.³¹

The ability to frame a public health issue successfully, to attract public and political support, is the core skill of advocacy. Neither tobacco control, nor any public health issue, is inherently newsworthy. Effective media advocates appear to have an ability to frame their concerns seamlessly in ways that make their issues instantly comprehensible in terms of wider discourses that reach beyond the manifest subject of their concerns. Such dimensions or “subtexts” allow audiences that may not have detailed knowledge or awareness about the particular details of a given issue to identify that here is something similar to an issue theydounderstand. Subtexts serve to link topics to familiar, wider sociopolitical discourses so that coverage of particular events is decoded by audiences as instances of more general themes or types of story. In this way, much news is not instruc- tively seen as news but as “olds”—essentially the retelling of age-old stories only with new casts, circumstances, particular details, and so on.²⁶ For example, the perennial tobacco control advocacy theme of the tobacco industry as predators on children’s health is essentially the retelling of the myth of the Pied Piper of Hamelin—a moral tale about the dangers of friendly strangers with seductive, deadly messages. A campaign urging full disclosure of tobacco additives is newsworthy because it evinces wider news dis- courses about consumers being duped by profit-hungry business and about the inherent dangers of chemical additives—two discourses that reach well beyond tobacco control.

Perhaps the most fundamental insight about advocacy is that if public health advocacy is essentially political, then politics is largely about the problem of multiple definitions of the same events or issues. This insight goes to the heart of advocacy strategy, where con- testing interest groups strive to frame episodes in ways that cause their definition of what

is at issue to become dominant. For example, the tobacco industry seeks to frame tobacco advertising as commercial freedom of expression, as a means of informing consumers about tobacco product qualities, or as the wealth-generating exercise of a legitimate industry that is being attacked unfairly by self-appointed, antibusiness “do-gooders.” For years, public health advocates have successfully reframed advertising as a highly researched, beguiling, and deadly tune whistled to the nation’s children by faceless trans- national corporations interested only in profit maximization. The public discourse about tobacco advertising has thus been a story of these two fundamentally different frames jousting for dominance. Opinion polls over 15 years have recorded a progressive level of majority popular support for advertising bans, suggesting that the public health frame has succeeded in securing the dominant position in this discourse.

Opportunistic and Responsive Advocacy Campaigns

Advocacy campaigns, while often highly planned and strategically governed, are also determinedly opportunistic and responsive to unfolding events. It is the nature of the advocacy process that the argument twists and turns with the efforts of the contesting par- ties to seize the initiative or with the entrance of different players into defining moments of debates. Unlike many in public health, advocates’ day-to-day actions are seldom gov- erned by research cultures where the sanctity of the “intervention” is paramount to con- cerns about evaluating efficacy. It would be unheard of for advocates to restrain them- selves from engaging in a strategy not originally planned because of concerns that the original campaign conception may be destroyed and evaluation disrupted. Yet such con- duct in clinical or health promotion intervention trials is akin to a capital offense, particu- larly in the face of the seemingly unstoppable incoming global tide of evidence-based medicine with its reductionist precepts.

This ever-changing, strategically complex nature of advocacy creates fundamental problems for those wanting to assess its impact and to learn which approaches are worth pursuing from past efforts. Unlike the comparatively simple task of specifying exactly what the intervention was in therapeutics and some areas of health education, it is seldom possible to specify the total contents of the “black box” in advocacy so that others may replicate apparently successful efforts. Where accounts of advocacy activity exist at all, they tend to exist as oral history held in the memories of those who were involved, recorded in fragmentary form in scrapbooks of news clips and the occasional descriptive account delivered to a conference. Australian analytic reviews of advocacy successes and failures are uncommon.^40-43

The low priority given to documenting the advocacy process is largely a function of the sorts of agencies and individuals involved in advocacy.⁴⁴Advocacy in Australia has been driven by a relatively small group of people working from an even smaller group of nongovernmental organizations (NGOs) and grassroots community groups. The main tobacco control advocacy groups in Australia have been the states’ cancer councils: the Australian Council on Smoking and Health; Action on Smoking and Health (ASH); the Australian Medical Association; the Non Smokers Movement; and, in the early 1980s, two radical community groups, MOP UP (Movement Opposed to the Promotion of Unhealthy Products)⁴⁰and BUGA UP (Billboard Utilising Graffitists Against Unhealthy Promotions).^17,18,45Most of these organizations do not operate within a working culture that requires the documentation or anything remotely approaching a formal evaluation of

advocacy. Yet for decades, they have been almost daily “out there,” highly active and visi- ble as news actors. In this respect, they are very different from the sort of tobacco control culture that would be depicted in a snapshot of Australian tobacco control taken from scholarly journals. Interventions described in the latter are too often small, only occur once, and are of little consequence to population-wide influences on tobacco use.

The Attribution Problem in Advocacy

It is often asked, Does advocacy work? The question typically is asked by those whose epistemological comfort zones are threatened by the inherently “messy” nature of advo- cacy practice and the consequent challenges it poses to those wedded to wholly quantita- tive research paradigms set in the time-limited windows required in funded evaluation cycles.⁴⁶The question invites those of whom it is asked to step inside a scientific model appropriate to testing the efficacy of therapeutic agents and diagnostic tests, surgical pro- cedures, and vaccines and, once inside, to compete on those terms in explaining efficacy.

Such research conditions require that randomization be possible, that confounders are accounted for, and that the intervention can be both explicitly specified and replicated by others, so that we can be confident (for example) that a drug administered in a given regi- men will produce predicted outcomes no matter who prescribes or ingests it.

In advocacy, as will be seen in the following case studies, many influences come to play in the environments in which the goals of advocacy are finally achieved. These influ- ences are often neither meaningfully discrete nor easily quantifiable, and they often “run”

simultaneously and are frequently unrecorded and ignored in research.⁴⁶Wakefield and Chaloupka have called for the broadening of the research gaze onto influential “inputs”

that go way beyond the traditional objects of tobacco control research such as antismoking advertising campaigns.⁴⁷The most outstanding example of this is the his- toric neglect of studying the role of news and other media coverage in influencing com- munity and political attitudes. In 1999, 8,738 instances of press, radio, and television reports on tobacco were monitored in Australia.⁴⁸Previous studies of smaller samples show that the great majority of this coverage is reported in terms that are supportive of tobacco control.^38,49While government-funded quit and prevention campaigns typically are thoroughly evaluated,⁵relentless news coverage of tobacco control issues, which across any year dwarf these campaigns, has been all but ignored for the ways it might influence personal, community, and political perspectives on tobacco. It is as if it were mere background “noise” rather than the fruits of deliberate efforts by advocates to change public and political opinion.

The time frames in which advocacy efforts move from the initial engagement with an issue through to (for example) the eventual passage of the final component of a compre- hensive advertising ban generally span years, if not decades. This contrasts with the time-limited duration of most studies of campaign effectiveness in health promotion, where periods of months and, less commonly, years are examined, on the assumption that too many confounding variables will intervene over longer periods.

Trust and Persistence

It would be easy to gain the impression from the preceding discussion that all effective advocacy occurs by pressure exerted from those outside government. This is incorrect.

Unlike in the United States, where civil servants are expressly forbidden to engage in any

political or legislative action under the terms of the Hatch Act,⁵⁰in Australia, some highly influential bureaucrats and other government advisers have engaged in very difficult bal- ancing acts in advocating for policy change from within government. Access to trusted advice from a well-informed government adviser has been important for health ministers about to take the leap on an issue or under fire from their opposition. Australian govern- ments are fortunate to have had some staffers who understand and are concerned about tobacco control issues, are experienced in engaging with the tobacco industry, and inter- act sufficiently with trusted advocates outside government to play very important

“insider” roles in advancing tobacco control. Strategically placing items onto the agenda for ministerial meetings, interpreting and reframing advocacy messages from NGOs so that they are more palatable to ministers, and being creative with the raw materials of leg- islative language are all important components of the advocacy process. Furthermore, given that the wheels of most governments turn slowly and many issues compete for attention, being patient and persistent are necessary qualities for “picking the right moment” to present or re-present an issue for discussion. None of these people would conceive of themselves asadvocates—some would be offended at the term. If the modus operandi of advocates outside government is difficult to document, the approaches employed by government advisers are even more difficult to encapsulate and lay bare for critical appraisal. These people are integral parts of the momentum and the machinery that move policy making forward.

CASE STUDY 1: PROMOTING SMOKE-FREE INDOOR AIR

Since the mid-1970s, the tobacco industry has identified passive smoking as “the most dangerous development to the viability of the tobacco industry that has yet occurred”⁵¹ because restrictions on smoking reduce smoking opportunities and, therefore, total ciga- rettes smoked by about 20% per day.⁵²In 2000, the New South Wales health minister announced that the government would ban smoking in restaurants.⁵³The announcement followed the introduction of bans in three other states and territories. Calls for govern- ments to legislate for restaurants and other public indoor areas to ban smoking have been routine among the policies of health agencies since the early 1980s and were imple- mented by large organizations from around 1986. Countless press releases, media inter- views, and publicized submissions to government enquiries have called for restaurant smoking bans for nearly 20 years, so the following question arises: What caused these calls to finally come to fruition in 2000?

In casual conversation, the first author asked a source close to the minister to explain,

“Why now?” He replied that the health minister had recounted a “straw that broke the camel’s back” incident in which the minister had been in a restaurant with his children, one of whom was asthmatic. A request to a nearby diner to stop smoking was ignored. The minister saw this incident as a challenge for his public role.

The above account provides one level of explanation as to why the ban was introduced and underscores an important advocacy principle that key decision makers should not be conceptualized only as political or bureaucratic functionaries who are receptive only to evidence-based argument but also as people who can potentially engage with issues in their roles as family members, citizens, patients, and consumers. Advocates have sought to make decision makers engage with issues at a personal level, rather than to experience

them only as some abstract policy issues. Such engagement has sometimes been engi- neered by setting up personal encounters that can often become top-of-mind in political assessments.

Some seekers of an explanation for the ban would conclude, from the proximity of the minister’s personal experience to the announcement of the ban, that this was “how it hap- pened,” yet such a conclusion would ignore 20 years of advocacy that helped create the climate in which the decision to ban smoking could be made. Twenty years ago, most Australians would have sat in smoke-filled restaurants uncomplainingly and never con- sidered that environmental tobacco smoke was harmful or that dining out could occur in a smoke-free setting. In the intervening period, an immense amount of advocacy occurred, aimed both generally at raising awareness of the health aspects of passive smoking and at targeting specific policy objectives such as public transport, airlines, workplaces, shop- ping centers, and sports stadia.

Some of the events and incidents that attracted much media attention are listed below.

• There were vanguard cases of personal litigation by individuals who sued their employers,⁵⁴airlines that did not provide smoke-free seating as advertised,⁵⁵and nightclubs that were argued to be discriminating against asthmatics whose health would be affected by tobacco smoke.⁵⁶ These cases were highly newsworthy because the litigants were seen to be ordinary citizens taking a brave stand that would benefit many Australians and shamed inactive governments. Tobacco con- trol advocates often worked closely with such individuals, assisting with journalis- tic contacts and backing them up with subsequent advocacy.

• Arguments were made that passive smoking was an occupational health issue akin to asbestos removal from buildings, noise, and dust standards.⁵⁷This sought to engage the trade union movement in accepting workplace smoking as an occupa- tional rather than a personal health issue.

• There was a successful federal court challenge by a small consumer group to a mis- leading press statement about environment tobacco smoke (ETS) made by the tobacco industry.^58,59Here, the David and Goliath metaphor sustained press interest, as well as the core interest in the implications for legal liability. Following the case,

“concern about litigation” replaced “health” as the primary motivation of employ- ers introducing smoke-free workplaces.⁶⁰

• Major publicity was given to expert reports on passive smoking^61,62and to the state- ments of high-profile visiting international experts who were able to argue that lack of government action placed Australia at risk of appearing to be a policy backwater compared with places such as California, where bans have been implemented to wide acclaim.

• There was controversy surrounding highly paid scientific and medical consultants to the tobacco industry who published a report that, predictably, downplayed the risks of passive smoking.⁶³This long-running story satisfied the news media’s appe- tite for investigating concerns about “cash for comment.”⁶⁴

• There was the cultivation and widespread use of apposite sound bites such as “a nonsmoking section in a restaurant is about as useless as a nonurinating section in a swimming pool.”

• There has been the regular commissioning of opinion polls showing large and increasing public support for smoke-free indoor air.⁵⁷

The Importance of Precedent

Australia has a federal system of government, with a central six-state and two-territory government. Because different political parties govern in each of these jurisdictions and different parties seldom cooperate on legislation, the states’ public health laws are often different, and the task of advocating for nine governments to uniformly adopt a law or pol- icy is formidable. With nations such as the United States and Canada having 50 and 13 governments, respectively, this appears to be an international problem. It has been impor- tant for Australian tobacco control advocates to try to establish policy or legislative prece- dents that benchmark the art of the possible. The Australian Capital Territory (ACT) is the smallest seat of government, and with a more highly educated population, it usually has a progressive government. As such, it was a natural site of the weakest link in the national chain of tobacco industry-supported resistance to restaurant, club, and bar smoking bans.

Once broken by the successful and popular ban introduced in 1994, the ACT ban became a reference point to dispel industry scare mongering that the hospitality industry would face ruin because of smokers’ reduced dining.⁶⁵

The ACT ban caused a slow domino effect that, within 6 years of its introduction, saw six out of eight states and territories move to ban smoking in restaurants. One has also moved to ban smoking in gaming rooms of casinos, following advocacy by croupiers that their occupational health was being put at risk.⁶⁶In less than 20 years and in the face of perhaps the most concerted and heavily funded international tobacco industry counteradvocacy ever mounted,^63,67smoking in public indoor areas is now playing out its endgame in Australia.

CASE STUDY 2: BANNING TOBACCO ADVERTISING

Between September 1973 and September 1976, direct advertising of cigarettes was phased out on Australian radio and television. In subsequent years, legislation banned remaining forms of advertising in print media (July 1993), outdoor (January 1996), and through sponsorship. In 1999, several states began to end the final remaining form—point-of-sale advertising—and to greatly limit the number of packs permitted to be displayed.¹²In the early 1970s, tobacco was one of the most heavily advertised com- modities in Australia. Today, the Australian industry is forced to rely on advertising

“leakage” from small-circulation magazines imported from overseas; international broadcasts of sponsored sporting events; and the one remaining exemption, the Mel- bourne Formula One Grand Prix (although this loophole will close in 2006).

The “Half-Pregnant” Principle

Again, precedent proved critical to the task of widening bans on advertising in Austra- lia. The initial broadcast media ban was introduced on the twin pretext that smoking should be discouraged particularly in children and that the broadcast media were seen as particularly influential. Once these two assumptions had been enshrined in law, it only remained for advocates to demonstrate that tobacco advertising in other media was also capable of influencing children. This allowed the subtext of the absurdity and inconsis-

tency of “half-pregnant” government policy to be repeatedly voiced, from which there was no escape. Advocates were readily able to demonstrate that children read magazines thick with tobacco advertising, rode to school in buses bedecked in it, and not only flocked to sporting events sponsored by tobacco but also preferred the sponsoring brands. At the height of the “half-pregnant” farce, some state governments supported an industry-negotiated voluntary code of advertising restraint that stopped outdoor tobacco advertising being located less than 200 meters from schools. The logic here was that a tobacco billboard 199 meters from a school might influence children to smoke, while the same billboard 201 meters away was presumably innocuous. Under the weight of this continually exploited absurdity, the other media fell to progressive increments in the law as it moved toward a total ban.

The tobacco industry was unable to defend the “half-pregnant” principle and looked to the financial hopes of the media and sponsored sporting and cultural bodies to be allowed to keep themselves recipients of the tobacco industry’s financial resources. This shifted the debate to the relative merits of sporting groups’ claims to be sponsored by a “legal product” and the efforts of advocates to frame their interest in money as being “blood money” transacted to allow the industry to make its products attractive to youth.

It has been very challenging to advocates to sustain media and, therefore, public and political interest in banning tobacco advertising over the 25 years that it took to ban all forms of advertising. Therefore, the “news” on tobacco advertising needed to be regularly packaged in ways that would not cause journalists to reject it as a stale, worn-out story.

Some of the highlights of advocacy to end all tobacco advertising in Australia include the following:

• Publicity surrounded efforts by a small group of health workers to have the actor Paul Hogan removed from Winfield advertising because of his immense appeal to children.⁴⁰Again, the David and Goliath or “mouse that roared” metaphor sustained much of the media interest in this episode, with one headline reflecting it explicitly as “MOP UP’s slingshot cuts down the advertising ogre.”⁶⁸

• There was a 6-year, Australia-wide civil disobedience billboard graffiti campaign in which doctors, teachers, and ordinary citizens risked jail terms but were mostly given token fines by courts and received widespread news coverage.¹⁸This pro- tracted campaign involved no more than 50 people and probably did more than any other advocacy initiative to transform the popular understanding of tobacco control from being a puritanical exercise akin to the temperance movement to one that embodied values about citizens seeking to advocate at considerable risk to their careers on behalf of children and tobacco victims. Importantly, this civil disobedi- ence campaign also served to make other tobacco control groups more radical. The definition ofradicalcame to include civil disobedience—what was formerly con- sidered as “radical” now became defined as moderate by comparison. Groups that had been hesitant to enter the advocacy fray and call for a total advertising ban now found such a position unacceptably timid—thereafter, the call became the policy of virtually all health agencies.

• There were strategies of finding and supporting sporting and cultural celebrities prepared to speak out against their sport being used to promote tobacco. This wid- ened the range of the players in the debate beyond the usual cast of health advocates:

people from within the areas supposedly benefiting from tobacco were now “biting the hand that fed them” or whistle-blowing on an ethical dilemma—two more news- worthy themes.

• There was the picketing of the Australian Open tennis championship during the years it was sponsored by a tobacco company, eventually causing tennis officials to switch to an automobile manufacturing company.¹⁸Many other sporting and cul- tural events were similarly “gate-crashed” by demonstrators intent on capturing some of the news coverage given to these events and thereby demonstrating that tobacco sponsorship was controversial.¹⁸

• There was the “buyout” of sporting and cultural tobacco sponsorship via the addi- tion of a 5% state tobacco tax, used to replace these sponsorships with messages about public health issues such as quit smoking and skin cancer prevention.²¹This strategy, which required painstaking lobbying on all sides of politics, was the coup de grace for tobacco sponsorship, as it totally undermined the economic depend- ence argument that had allowed the industry to build strategic alliances with high-profile sports, dependent on industry largesse.

Size Matters

In considering the issue of why Australia has done well in particular areas of tobacco control, it must be concluded that sizedoesmatter. Australia has a relatively affluent and well-educated population of only 19 million people. The network of advocates and gov- ernment staffers who are informed about tobacco issues is relatively small, mostly known to each other and generally able to coordinate its efforts efficiently. Although all politi- cians spend their days juggling many political agendas, it is not as difficult for determined advocates in Australia to gain access to critical gatekeepers in government as it is in larger countries where many more advocates compete for attention on other issues. This also applies to the scale and range of issues competing for attention of newspaper editors and journalists.

In relatively small governments, one or two motivated politicians can make all the dif- ference, whereas in larger political systems such as the United States, the successful pas- sage of policy initiatives requires many political players to agree to pursue the same objective. Another factor in the success of tobacco control advocacy efforts may be the declining quality of opposition in the tobacco industry. One Australian executive recruit- ment agency manager has said,

I don’t think there’s any doubt that it’s harder to get enthusiasm for tobacco companies.

There is a trend. If you have ten qualified candidates and you tell them it’s a tobacco com- pany, five might say they don’t want the job. . . . The people who’d be contenders for the senior positions are not likely to be attracted to a sunset industry. (P. 14)⁶⁹

Although industry opposition to policy change has always been vigorous and formidable, it has not, in general, involved the scale of opposition and intimidation that has been evi- dent in countries such as the United States. In overview, then, these size-related factors are likely to have been important ingredients in facilitating advocacy in Australia and enabling it to become the “seedbed” for battles yet to be fought in other countries with more complex and challenging political systems.¹

Involving Communities?

A doctrine that has gained considerable support in health promotion circles is that for advocacy to succeed and for its gains to be sustained, it must emanate from and be driven by communities as a “bottom-up” expression of their concerns and priorities. They must be empowered through what Petersen critically reviewed as the “poetics and politics” of community development.⁷⁰ In summary, this doctrine holds that “top-down” policy change is imposed by public health elites that have neither consulted their communities nor worked to empower community members to become effective advocates for change.

The doctrine argues that without the support of communities, the fruits of such top-down advocacy are unlikely to be supported.

How does this doctrine fit with the Australian tobacco control advocacy experience?

In short, not very well. The popular view is that smoking is a voluntary activity and, there- fore, categorically different from many of the “imposed” health problems that public health advocacy typically addresses (e.g., violent communities, environmental health concerns such as leaded petrol, lack of access to health facilities, unsafe public utilities and infrastructure). Advocacy also is often undertaken on behalf of groups unable to speak up for their own interests, such as children. These two considerations suggest that tobacco control advocacy is likely to attract community involvement only in the areas of environmental tobacco smoke (because of the way it is imposed on others) and on behalf of children (such as actions to stop shopkeepers selling tobacco to children). In addition, because tobacco has caused diseases that typically manifest themselves decades after individuals commence smoking, it seems unlikely that tobacco control would attract as much grassroots attention as public health issues that cause more acute health problems in which solutions bring promise of immediate benefit.

This assessment has been confirmed broadly by the recent history of tobacco control in Australia. The vanguards of tobacco control advocacy in Australia have in only three cases (the Non Smokers Movement and BUGA UP, as well as in the case of individual liti- gants) been located predominantly in the lay community. On all other issues, advocacy has been driven by professionals within NGOs and dedicated advocacy offices that are set up explicitly to pursue these objectives. As these groups began to set the agenda for tobacco control reform, indices of community support for tobacco control showed rapid signs of positive growth. While professionals were most often newsmakers, letters to the editor in newspapers and calls to talk-back radio programs increasingly have featured the expressions of ordinary citizens’ concerns about the same range of issues. As stated ear- lier, in several celebrated cases, citizens have played key roles in litigation, although in all cases these were supported by professional advocates who assisted with expert informa- tion, publicity, and general support.

Tobacco control advocacy in Australia, then, did not emerge spontaneously out of the community except in some small, if important, instances. Rather, it has mostly been initi- ated by professional advocates who took the recommendations of the early expert reports on reducing the tobacco epidemic and the results of relevant local policy-relevant research and advocated for changes to be adopted. While today there are countless exam- ples of citizens joining in this advocacy (e.g., by complaining to management in smoky restaurants and declaring their workplaces smoke free), the leading edge of contemporary advocacy for tobacco control (e.g., to secure strengthened pack warnings⁷¹or regulation of tobacco as a product) is still being driven almost wholly by health NGOs and pol- icy-oriented researchers.

References

1. Philip Morris (Australia):Corporate Affairs Planning Document, 1992 [Online]. Available:

www.pmdocs.com. Bates no. 2023240608_0627. Accessed November 30, 2000.

2. Turner C:Tobacco: The Battle for Social Acceptance. Speech delivered to 6th World Tobacco E x h i b i t i o n a n d S y m p o s i u m , Vi e n n a , O c t o b e r 1 9 9 0 [ O n l i n e ] . Ava i l a b l e : http://www.rjrtdocs.com/frames.jsp. Bates no. 511970081_0099. Accessed November 30, 2000.

3. World Health Organization:Tobacco or Health: A global status report. Geneva, WHO, 1997 [Online]. Available: http://www.cdc.gov/tobacco/who/whofirst.htm. Accessed December 18, 2000.

4. Woodward S, Winstanley M, Walker N:Tobacco in Australia: Facts and Issues, 1995 [Online].

Available: www.quit.org.au/FandI/fandi/c01s1.htm#c01t1. Accessed November 30, 2000.

5. Hassard K (ed.):Australia’s National Tobacco Campaign: Evaluation Report(Vol. 1). Can- berra, Commonwealth of Australia, 1999.

6. Hill DJ, White VM, Scollo MM: Smoking behaviours of Australian adults in 1995: Trends and concerns.Medical Journal of Australia168:209-213, 1998.

7. Australian Institute of Health and Welfare:Australia’s Health 2000. Canberra, Australian Insti- tute of Health and Welfare, 2000.

8. Morgan LC, Grayson D, Peters HE, Clarke CW, Peters MJ: Lung cancer in New South Wales:

Current trends and the influence of age and sex.Medical Journal of Australia172:578-580, 2000.

9. Tyrell I:Deadly Enemies: Tobacco and Its Opponents in Australia. Sydney, University of New South Wales Press, 1999.

10. Gray N, Hill D: Cigarette smoking, tar content, and death-rates from lung cancer in Australian men.Lancet1:1252-1253, 1975.

11. Anderson P, Hughes JR: Policy interventions to reduce the harm from smoking.Addiction 95(suppl. 1):S9-11, 2000.

12. Barnsley K, Jacobs M: World’s best practice in tobacco control: Tobacco advertising and dis- play of tobacco products at point of sale: Tasmania, Australia.Tobacco Control9:230-232, 2000.

13. Centre for Behavioural Research:Cancer: Health Warnings and Content Labelling on Tobacco Products. Carlton, Australia, Anti-Cancer Council of Victoria, 1992.

14. Egger G, Fitzgerald W, Frape G, Monaem A, Rubinstein P, Tyler C, McKay B: Results of large scale media antismoking campaign in Australia: North Coast “Quit for Life” programme.Brit- ish Medical Journal, Clinical Research Edition287:1125-1128, 1983.

15. Pierce JP, Dwyer T, Frape G, Chapman S, Chamberlain A, Burke N: Evaluation of the Sydney

“Quit for Life” anti-smoking campaign: Part 1. Achievement of intermediate goals.Medical Journal of Australia144:341-344, 1986.

16. Quit Victoria:Quit Evaluation Studies Vol. 9, 1998 [Online]. Available: www.quit.org.au/

QE9/QE9Home.html.

17. Chesterfield-Evans A: BUGA-UP (Billboard Utilizing Graffitists Against Unhealthy Promo- tions): An Australian movement to end cigarette advertising.New York State Journal of Medi- cine83:1333-1334, 1983.

18. Chapman S: Civil disobedience and tobacco control: The case of BUGA UP.Tobacco Control 5:179-185, 1996.

19. Wilson DH, Wakefield MA, Esterman A, Baker CC: 15’s: They fit anywhere—especially in a school bag: A survey of purchases of packets of 15 cigarettes by 14 and 15 year olds in South Australia.Supplement to Community Health Studies9(1):16-20, 1987.

20. Scollo M, Sweanor D: Cigarette taxes.Tobacco Control8:110-111, 1999.

21. Holman CD, Donovan RJ, Corti B, Jalleh G, Frizzell SK, Carroll AM: Banning tobacco spon- sorship: Replacing tobacco with health messages and creating health-promoting environments.

Tobacco Control6:115-121, 1997.

22. Bible G:Corporate Affairs Conference/Action Plan(confidential), December 13, 1988 [Online].

Available: www.pmdocs.com. Bates no. 2021596422_6432. Accessed November 30, 2000.

23. Borland R, Morand M, Mullins R: Prevalence of workplace smoking bans in Victoria.Austra- lian and New Zealand Journal of Public Health21:694-698, 1997.

24. Borland R, Mullins R, Trotter L, White V: Trends in environmental tobacco smoke restrictions in the home in Victoria, Australia.Tobacco Control9:266-271, 1999.

25. Snow J:On the Mode of Communication of Cholera(2nd ed.). London, Churchill, 1854. Repro- duced inSnow on Cholera. New York, Commonwealth Fund, 1936.

26. Chapman S, Lupton D:The Fight for Public Health: Principles and Practice of Media Advo- cacy. London, BMJ Books, 1994.

27. Wallack L, Dorfman L, Jernigan D, Themba M:Media Advocacy and Public Health: Power for Prevention. Newbury Park, CA, Sage, 1993.

28. Wallack L, Woodruff K, Dorfman L, Diaz I:News for a Change: An Advocate’s Guide to Working With the Media. Thousand Oaks, CA, Sage, 1999.

29. Siegel M, Doner L:Marketing Public Health: Strategies to Promote Social Change. Gaithers- burg, MD, Aspen, 1998.

30. Ryan C:Prime Time Activism: Media Strategies for Grassroots Organising. Boston, South End, 1991.

31. Iyengar S:Is Anyone Responsible?Chicago, University of Chicago Press, 1991.

32. Keck ME, Sikkink K:Activists Beyond Borders: Advocacy in Networks in International Poli- tics. Ithaca, NY, Cornell University Press, 1998.

33. Gamson WA, Modigliani A: Media discourse and public opinion on nuclear power.American Journal of Sociology95:1-37, 1989.

34. Entman RM: Framing: Toward clarification of a fractured paradigm.Journal of Communica- tion43:51-58, 1993.

35. Stillman F, Hartman A, Graubard B, Gilpin E, Chavis D, Garcia J, Lap-Ming W, Lynn W, Manley M: The American Stop Smoking Intervention Study: Conceptual framework and evaluation design.Evaluation Review23:259-280, 1999.

36. Otten AL: The influence of the mass media on health policy.Health Affairs, Winter 1992, pp. 111-118.

37. Dow S: The politics of breast cancer.Weekend Australian Magazine, April 16-17, 1994, p. 35.

38. Christophides N, Chapman S, Dominello A: The new pariahs: How the tobacco industry are depicted in the Australian press. Australian and New Zealand Journal of Public Health 23:233-239, 1999.

39. Wakefield M, Miller C, Woodward S: Community perceptions about the tobacco industry and tobacco control funding.Australian and New Zealand Journal of Public Health23:240-244, 1999.

40. Chapman S: A David and Goliath story: Tobacco advertising in Australia.British Medical Jour- nal281:1187-1190, 1980.

41. Chapman S, Reynolds C: Regulating tobacco: The South Australian Tobacco Products Control Act 1986.Community Health Studies11(suppl.):9-15, 1987.

42. Chapman S: Anatomy of a campaign: The attempt to defeat the NSW Tobacco Advertising Pro- hibition Bill 1991.Tobacco Control1:50-56, 1992.

43. Winstanley M:Overview of the Lobbying for the Victorian Tobacco Act (1987). Melbourne, Anti-Cancer Council of Victoria, 1993.

44. Chapman S: Upgrading the academic respectability of advocacy studies in tobacco policy implementation.Tobacco Control2:81-83, 1992.

45. Billboard Utilizing Graffitists Against Unhealthy Promotions (BUGA UP) [Online]. Available:

www.buga-up.org. Accessed November 30, 2000.

46. Chapman S: Unravelling gossamer with boxing gloves: Problems in explaining the decline in smoking.British Medical Journal307:429-432, 1993.

47. Wakefield MA, Chaloupka FJ: Improving the measurement and use of tobacco control “inputs.”

Tobacco Control7:333-335, 1998.

48. Chapman S: Promoting smoking cessation in Australia: An update, inRelapse and Other Real- ities: An Update on Smoking Cessation Rates in Australia. Sydney, SmithKline Beecham, 2000, p. 15.

49. Chapman S: The news on smoking: Editorial coverage of tobacco and health issues in Austra- lian newspapers, 1987-88.American Journal of Public Health79:1419-1420, 1989.

50. United States of America:Political Activity: Hatch Act[Online]. Available: www.osc.gov/

hatchact.htm. Accessed November 30, 2000.

51. Roper Organization:A Study of Public Attitudes Toward Cigarette Smoking and the Tobacco Industry(Vol. 1). Roper Organization, 1978.

52. Chapman S, Borland R, Brownson R, Scollo M, Dominello A, Woodward S: The impact of workplace smoking bans on declining cigarette consumption in Australia and the USA.Ameri- can Journal of Public Health89:1018-1023, 1999.

53. Jacobsen G: Last gasp for public smoking.Sydney Morning Herald, May 3, 2000.

54. Woodward SD, Winstanley MH: Lung cancer and passive smoking at work: The Carroll case.

Medical Journal of Australia153:682-684, 1990.

55. Chapman S: Pecked to death by (flying) ducks: Court decision may extinguish smoking on air- craft.British Medical Journal311:38-40, 1995.

56. Chapman S: Smoky nightclub discriminated against woman with asthma.British Medical Jour- nal315:904, 1997.

57. Worksafe Australia:Guidance Note on Passive Smoking in the Workplace. National Health and Safety Commission Report 3019. Canberra, Commonwealth of Australia, 1994.

58. Chapman S: Australian court rules that passive smoking causes lung cancer, asthma attacks and respiratory disease.British Medical Journal302:943-945, 1991.

59. Chapman S, Woodward S: Australian court decision on passive smoking upheld at appeal.Brit- ish Medical Journal306:120-122, 1993.

60. National Heart Foundation (NSW Division):Smoking in the Workplace: A Survey of NSW’s Top Companies. Sydney, National Heart Foundation, 1993.

61. National Health and Medical Research Council:Effects of Passive Smoking on Health: Report of the NH & MRC Working Party on the Effects of Passive Smoking on Health. Adopted at the 101st Session of the Council, June 1986. Canberra, Australian Government Publishing Service, 1987.

62. National Health and Medical Research Council:The Health Effects of Passive Smoking. Can- berra, Australian Government Publishing Service, 1997.

63. Chapman S: “Vast sums of money . . . to keep the controversy alive”: The 1988 BAT memo.

Tobacco Control6:236-239, 1997.

64. ABC Radio National: Transcript of interview between Peter Thompson and Julian Lee. Decem- ber 7, 1994 [Online]. Available: www.pmdocs.com. Bates no. 2048548532_8538. Accessed November 30, 2000.

65. Goodin M, McAllister I: Evaluating compliance with Australia’s first smoke-free public places legislation.Tobacco Control6:326-331, 1997.

66. Murphy D: Casino fumes as smoking ban leaves cloud over the tables.Sydney Morning Herald, June 23, 2000.

67. Ong EK, Glantz SA: Tobacco industry efforts subverting International Agency for Research on Cancer’s second-hand smoke study.Lancet355:1253-1259, 2000.

68. Light D: MOP UP’s slingshot cuts down the advertising ogre.The Australian, May 12, 1980, p. 14.

69. Moodie P: Life’s a drag for tobacco men.Australian Financial Review, September 2, 1994, p. 44.

70. Petersen AR: Community development and health promotion: Empowerment or regulation?

Australian Journal of Public Health18:213-217, 1994.

71. Mitchell P, Chapman S, Smith W: “Smoking is a major cause of blindness”: A new cigarette pack warning?Medical Journal of Australia171:173-174, 1999.

View publication stats View publication stats