Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697642127840.pdf (Australia)
Submission to the Senate Select Committee on Tobacco Harm Reduction From: Dr Alex Wodak, The Progressive Public Health Alliance Date: 5th November 2020 ___________________________________________________________________ About The Progressive Public Health Alliance The Progressive Public Health Alliance is a collaboration that started in 2018, growing out of the struggle to achieve universal publicly funded access to health services and treatment for all Australians, and in particular, pioneering drug harm reduction programs.
We are driven by the decades long experience of our members in working with people and families affected by problematic drug use, smoking and alcohol abuse.

The Progressive Pub- lic Health Alliance has been set up to achieve positive change in access to publicly funded healthcare and harm reduction.

We are a not-for-profit incorporated association based in Melbourne, Australia and we are funded by donations from our members and supporters.
Progressive Public Health Alliance will not accept any funding or in-kind resourcing from industry or industry bodies in areas that it has involvement and does not accept any funding or in-kind resources from weapons manufacturers, pharmaceutical, gambling, tobacco and alcohol companies.

We work across and Australia and our region, linking in with other progressive health organ- isations and movements who are committed to the same goals in their communities.
Our members work with health professionals, carers, policymakers and the public to achieve our goals in providing universal healthcare, evidence based best practice in harm reduction and the detection, treatment and prevention of non-communicable diseases.

We have a governing board responsible for the direction and governance of the organisation, an executive officer and a small team of staff and volunteers who support our board.
1 Tobacco Harm ReductionSubmission 271 Biography of Alex Wodak I am a physician (though now retired voluntarily from medical practice and no longer registered).

I graduated in Medicine from Melbourne University in 1970, became a Fellow of the Royal Australasian College of Physicians in 1984 and later became a Fellow of the Chapter of Addiction Medicine of the Royal Australasian College of Physicians.

I have worked as a doctor in university teaching hospitals in Melbourne, London (1976-82) and Sydney.
I was a Senior Staff Specialist employed as Director of the Alcohol and Drug Service, St Vincent’s Hospital, Sydney from 1982 until I retired in 2012.

Together with others I established the first needle and syringe programme (1986) and first Medically Supervised Injecting Centre (1999) in Australia when both required civil disobedience.
Together with others I also helped establish the National Drug and Alcohol Research Centre (1987), the Australian Society of HIV Medicine (1989) and an organization run by and for people who use drugs, NUAA (the NSW Users AIDS Association, 1989).

I have published about 300 scientific papers and book chapters on alcohol and drugs.

I have also worked as a Short Term Consultant in about 40 countries – mainly Low and Middle Income Countries between Iran and China.
Much of this work was for United Nations or other international organisations including WHO, the World Bank, UNODC, UNAIDS and GFATM.

I was the Foundation President of the International Harm Reduction Association (1996-2004) and have also been President of the Australian Drug Law Reform Foundation.

I have been a member of many state, national and international committees.

I am not now and never have been funded by tobacco companies.
I have never and do not now own tobacco company shares (including in my superannuation).

I am a Director of the Australian Tobacco Harm Reduction Association.

The funding sources of the Australian Tobacco Harm Reduction Association are clearly spelt out in our published materials.

Yet I am frequently asked about my funding sources.

I have funded most of my expense incurred when advocating for tobacco harm reduction.
Are individuals and organisations critical of tobacco harm reduction asked about their funding sources?

Some individuals and organisations critical of tobacco harm reduction are funded directly or indirectly by organisations which profit from the sale of cigarettes.

Some are funded by US billionaires who support tobacco and nicotine abstinence.

2 Tobacco Harm ReductionSubmission 271 Executive Summary Tobacco harm reduction should be easy for Australia to accept and implement.
Australia officially endorses harm reduction in its National Tobacco Strategy.

Harm reduction is accepted as part of Australia’s National Drug Strategy of harm minimisation (along with supply reduction and demand reduction).

In addition, harm reduction is part of the 2003 Framework Convention on Tobacco Control which Australia has signed.

But instead tobacco harm reduction has become divisive and polarising.

Why?
Why?

Although there is some debate about tobacco harm reduction in other rich countries, none is as divided on this issue as Australia.

The core question is: should Australian smokers be able to easily switch from cigarettes, an extremely dangerous option, to vaping, a much less risky way of taking nicotine?

At present, it is possible but difficult in Australia to switch from smoking to vaping.
Proposed changes would make it even more difficult to switch from high risk to low risk ways of ingesting nicotine.

Australia needs strong support across all major political parties for tobacco harm reduction.
3 Tobacco Harm ReductionSubmission 271 Recommendations: 1 Endorse harm reduction as an equal partner to supply reduction & demand reduction as tobacco policy in Australia 2 Identify the paramount aim of Australia’s tobacco policy to be reducing smoking-related reducing deaths, disease and economic costs as fast as possible 3 Recognise that the highest priorities to achieve this aim is to accelerate an increase in quit smoking rates in older smokers while also reducing the harm from tobacco use 4 Recognise that, as smoking initiation rates in young Australians are already very low, that policy should also aim to continue this decline in smoking initiation 5 Recognise that accelerating the decline in smoking rates requires Australia to increase switching from smoking to vaping and/or other forms of tobacco harm reduction 6 Recognising that as vaping is fundamentally a consumer product, responsibility for nicotine for vaping should be transferred from the Therapeutics Goods Administration to the Australian Competition and Consumer Commission which would require exempting nicotine for vaping from the Poisons Standard 7 Regulating proportionately nicotine for vaping and other forms of tobacco harm reduction so that these products are appropriately labelled, in child proof containers and sold from vaping stores and certain other monitored retail outlets 8 Recognise vaping is the highest priority for tobacco harm reduction in Australia but as soon as possible other forms of tobacco harm reduction should be made available with proportionate regulation including snus, heated tobacco products and tobacco pouches 9 Recognise that maximising public health benefit of tobacco harm reduction options by nudging nicotine users from high to low risk options requires that these options need to be effective, safe, attractive, readily available and affordable.
10 Recognise optimal regulation proportionate to risk requires maintaining large price signal from high risk to low risk options, only known problematic flavours banned, allowing advertising to encourage switching and allowing vaping in public places subject to approval by local management authorities 11 Allow importation of regulated nicotine for vaping from overseas 12 Abandon the unworkable and excessive notion of prescription control for nicotine for vaping 13 Allow tobacco harm reduction options to be used in health and corrections facilities 4 Tobacco Harm ReductionSubmission 271 Smoking-related deaths and disease are the major long-term public health problem in Australia An estimated 21,000 Australians and world wide almost eight million people die each year from smoking-related conditions.
The number of deaths from smoking in Australia each year exceeds the number dying from the combination of alcohol plus prescription drugs plus illicit drugs HIV plus road crash deaths plus suicide.

Indeed many of the people struggling with problems due to alcohol, prescription or illicit drugs will die from a smoking related condition.

Although many of the Australians who die from a smoking-related condition are elderly, almost a third are of working age.
Tobacco use contributes to health burden more than any other risk factor and was responsible for 9.3% of the total burden of disease in Australia in 2015.

Two of every three long term smokers will die from a smoking related disease COVID increases the need to protect public health For some time to come, COVID will continue to be the most urgent public health issue in Australia.
COVID will make it even more important to improve public health and reduce as much as possible pressure on the health care system.

An unexpectedly low prevalence of smoking has been found among patients hospitalised with COVID.

Smoking, social and economic disadvantage and health inequity Smoking rates are more than twice as high among the lowest quintile of the Australian population compared to the highest quintile of the Australian population.
It has been estimated in the UK and US that people with mental illness consume about 40% of the cigarettes smoked.

High smoking rates are also seen in people with severe alcohol and drug problems, Aboriginal and Torres Strait Islander Australians, the homeless and people entering prisons.

Smoking is the major cause of health inequity in Australia.
Not only do low- income populations have higher smoking rates, they also start smoking at a younger age and smoke more cigarettes per day than higher income populations.

Consequently they have a higher incidence of smoking-related deaths and diseases.

An estimated one quarter of the life expectancy gap between Aboriginal and Torres Strait Islander people and majority Australians has been attributed to smoking.
Cost of smoking for smokers and the community Taxation on cigarettes was increased in Australia nine times in the last ten years.

This involved an increase of 25% in 2010 and then further increases of 12.5% annually eight times from 2013 to 2020.

Australian cigarettes are now the most expensive in the world.

The increase in the price of cigarettes in Australia has occurred in a period when wage growth has been minimal and has predominantly affected low-income populations.
Australia is now experiencing its worst economic recession since 1929.

Tobacco policy in Australia Australia began responding vigorously to the serious threat smoking poses to health and well being in the 1970s.

This was earlier than most other high-income countries.

Policy had two major aims.

First to reduce the initiation of smoking among teenagers and people in their early twenties as few start smoking after their early twenties.

Second to increase the quit rate of older smokers.


5 Tobacco Harm ReductionSubmission 271 Smoking rates have declined steadily over recent decades.

Many would have preferred to see smoking decline even faster but at least the rates were coping down at a reasonable rate.

Smoking rates are a useful proxy for what is the real aim of policy: to reduce smoking- related deaths and disease, especially cancers, heart and lung disease.
Use of harm reduction to mitigate risk and harm Harm reduction aims primarily to reduce the adverse health, social and economic costs of a problematic risk behaviour without necessarily reducing that behaviour.

Drug harm reduction is often remarkably effective.

An independent evaluation of Australia’s needle syringe programme between 2000-2009 found that it prevented an estimated 33,000 HIV infections, 99,000 hepatitis C infections, cost $200 million and saved between $2.4 and $7.7 billion.
A $1 investment in Australia’s needle syringe programme saved $4 in healthcare costs and $28 overall.

Yet to get Australia’s needle syringe programme to commence before an HIV epidemic began spreading among people who inject drugs and the general population, civil disobedience was required.

Harm reduction is used widely in health, road safety and public policy.
Examples of harm reduction include: car seat belts, airbags, motorcycle helmets, bicycle helmets, frangible roadside poles and encouraging swimmers to swim between the flags.

Condom promotion is used to reduce unwanted pregnancies and sexually transmitted infections (including HIV).

Other examples of sexual health harm reduction include vaccination against the Human Papilloma Virus and male circumcision.
Harm reduction complements and does not attempt to replace other policy attempts to reduce the problematic risk behaviour.

Harm reduction has been used extensively and very effectively to reduce the spread of SARS-COV-2.

Physical distancing, hand washing, and mask wearing are all forms of harm reduction in that people still go about their usual activities but the risk of a deadly virus spreading is greatly reduced.

Harm reduction is often used to reduce the adverse effects of illicit drugs.
Examples include methadone treatment for people with problems from heroin, needle syringe programs to reduce HIV spread among and from people who inject drugs, drug consumption rooms to reduce drug overdose deaths and improve neighbourhood amenity, Heroin Assisted Treatment to assist people with severe problems who have been treatment refractory.

Pill testing is the most recent example of drug harm reduction to be vigorously opposed on introduction.
Harm reduction is also used to reduce alcohol-related problems.

Examples include thiamine fortification of flour to reduce Wernicke Korsakoff Syndrome (brain damage).

Harm reduction is used extensively in licensed premises (ie pubs) to reduce violence.

Examples include heavy furniture bolted to the floor, plastic drinking containers replacing glasses, requirement for food and non-alcoholic beverages to be available.

Efforts continue to reduce high-risk drinking.


Nicotine Replacement Therapy is also an example of tobacco harm reduction as nicotine is provided without the toxic products of combustion from smoking.

It is these toxic products, 6 Tobacco Harm ReductionSubmission 271 including tars and carbon monoxide, which arte responsible for the major harms of smoking.

Nicotine Replacement Therapy for smokers is analogous to methadone treatment for treatment of heroin dependence.
Snus is a very important form of tobacco harm reduction.

It originated in Sweden about 200 years ago.

Snus involves a fine-cut, moist form of tobacco which is often pasteurised.

The tobacco is contained in a pouch which looks like a tea bag.

The pasteurisation reduces or removes bacteria which produce tobacco-specific nitrosamines, responsible for cancers associated with tobacco smoking.

Snus has been extensively evaluated for decades.

Snus use is far more common among men than women in Sweden.
It is legal in Sweden but banned in all other European Union countries.

Rates for smoking, smoking-related diseases and smoking-related deaths are much lower among men in Sweden compared to men in all other EU countries and lower in Swedish men than women.

Snus is often referred to as ‘proof of concept of tobacco harm reduction’.

Trajectory of drug harm reduction over time New drug harm reduction interventions are generally fiercely resisted for many years after being introduced.
This is trued in Australia as it is on most countries in the world.

The opposition continues long after substantial benefits and minimal adverse effects have been demonstrated.

This is particularly true in the case of problematic risk behaviours which are considered pleasurable.

There was little opposition to the introduction of car seat belts but methadone treatment, needle syringe programs, drug consumption rooms, Heroin Assisted Treatment and pill testing were all vehemently opposed.
Harm reduction interventions are most likely to be vigorously opposed if the problematic risk behaviour involves pleasure that many in the community are uncomfortable about.

This includes especially illicit drug use and sex outside marriage.

Why are harm reduction interventions for problematic risk behaviours opposed so often?
The concern is often that if the problematic risk behaviours becomes less dangerous, more people will engage in the risk behaviour, or some will engage in the risk behaviour for a longer duration or more frequently.

Some psychologists believe that people keep their risk at an equilibrium level.

If the risk becomes less, then the risk behaviour increases.

This is called the ‘risk compensation hypothesis’.

Sometimes people do engage in a risk behaviour more if the risk level has decreased.
But this happens rarely.

Nevertheless, all new harm reduction interventions should be evaluated carefully to ensure that net harm has been decreased and that the problematic risk behaviour has not increased.

Although new forms of drug harm reduction are usually bitterly opposed initially, they are generally accepted eventually and prove to be very successful.

People or organisations betting against a new form of drug harm reduction are likely to lose.
Why is vaping so important for reducing the harm from smoking?

Public Health England and the UK Royal College of Physicians estimated after reviewing the evidence that at most, vaping is 5% of the risk of smoking.

Even if that quantitative estimate is not accepted, there is broad agreement that vaping is much less risky than smoking.

That alone makes vaping important.

Vaping is also very attractive to many smokers.


It provides almost as much nicotine as smoking and nicotine is very important to smokers.

It also reproduces many aspects of the 7 Tobacco Harm ReductionSubmission 271 smoking ritual: the hand to mouth movements; a jet of hot air hitting the back of the throat; billowing clouds blown into the air; and tastes and smells smokers learn to love.

In Australia and many other countries, vaping is the most popular way of quitting smoking.
Vaping is also the most effective method of quitting smoking.

The recent Cochrane Collaboration review confirmed that vaping is by far the most effective way of quitting smoking.

Vaping also has considerable public health impact because of the combination of being so popular and also so effective.

In addition, vaping is the only form of quitting where large numbers of smokers ‘quit accidentally’.
It is common to hear smokers say that they tried vaping out of curiosity but very soon found that they had switched over completely to smoking without having originally intended to quit smoking.

Is vaping also a form of disruptive innovation?

Vaping was developed in Beijing in 2003 and came to the commercial market in 2006.

It began to become popular in the UK and US in about 2013.

The first investment in vaping by a tobacco company was in 2012.
Tobacco companies own less than 20% of global vaping and none of Australian vaping.

But tobacco companies have realised that vaping and other forms of tobacco harm reduction represent a serious threat to their very lucrative industry.

A packet of 20 cigarettes costs tobacco companies less than 30 US cents to make but is sold for about $US 2.40.
Vaping and other forms of tobacco harm reduction are disruptive innovations in the same way that digital cameras were a disruptive innovations threatening the analogue camera and film industries.

Another example is smartphones which have disrupted many industries.

Betting against a disruptive innovation, as Australia is now doing with its de facto prohibition of vaping, is bound to fail.
8 Tobacco Harm ReductionSubmission 271 The committee will inquire into tobacco reduction strategies, with particular reference to: a. the treatment of nicotine vaping products (electronic cigarettes and smokeless tobacco) in developed countries similar to Australia (such as the United Kingdom, New Zealand, the European Union and United States), including but not limited to legislative and regulatory frameworks; b. the impact nicotine vaping products have had on smoking rates in these countries, and the aggregate population health impacts of these changes in nicotine consumption; c. the established evidence on the effectiveness of e-cigarettes as a smoking cessation treatment; d. the established evidence on the uptake of e-cigarettes amongst non- smokers and the potential gateway effect onto traditional tobacco products; e. evidence of the impact of legalising nicotine vaping products on youth smoking and vaping rates and measures that Australia could adopt to minimise youth smoking and vaping; f. access to e-cigarette products under Australia’s current regulatory frameworks; g. tobacco industry involvement in the selling and marketing of e-cigarettes; and h. any other related matter.
Dr. Alex Wodak AM, Emeritus Consultant, Alcohol and Drug Service, St Vincent's Hospital, Sydney Director, Australian Tobacco Harm Reduction Association President, Australian Drug Law Reform Foundation Director, Australia21 9 Tobacco Harm ReductionSubmission 271