Tobacco controlled – what will it take? Oceania Tobacco Control, Brisbane October 2011 Richard...

Tobacco controlled – what will it take?

Oceania Tobacco Control, Brisbane October 2011

Richard Edwards

Department of Public Health, University of Otago,

Wellington, New Zealand

Acknowledgements Many, many colleagues who work on tobacco control related

research

Particular thanks to:ASPIRE 2025 team+ Julian Crane and Rob McGee

Nick Wilson Anaru WaaTony Blakely

+ Many others

Structure

What do we mean by tobacco controlled?

Achieving the vision• It is possible!• Some challenges• Some thoughts about the how?

Another (even bigger) challenge Conclusions

Endgame as a goal Zero (or very close to) smoking/tobacco use

prevalence/consumption (Finland, NZ Govt) No/minimal supply of tobacco (Bhutan, NZ govt) Zero or close to zero uptake of tobacco (NZ Tupeka Kore

Vision) Zero or close to zero tobacco related mortality and morbidity

(US Department of Health and Human Services)

A society in which tobacco use is fully denormalised A society in which children are fully protected from tobacco

(NZ Tupeka Kore Vision)

NB Equity issues – ‘….for all social and ethnic groups’.

Endgame as a philosophy

Rejection of the status quo:• i.e. gradual decline in use and prevalence and

incremental policy advances Radical solutions to address an

unacceptable situation Aims to achieve endgame goals quickly

= PARADIGM SHIFT

Percentage smoking by ethnicity, 1991-2007 Pe

rcen

t

0

10

20

30

40

50

60

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

Maori Pacific peoples European/Other All

Source: Statistics New Zealand; ACNielsen (NZ) Ltd, reported in Tobacco Trends 2007

Endgame as a philosophy

Rejection of the status quo:• i.e. gradual decline in use and prevalence and

incremental policy advances Radical solutions to address an

unacceptable situation Aims to achieve endgame goals quickly

= PARADIGM SHIFT

Endgame as a process

Having an explicit government intention and plan to achieve close to zero prevalence of tobacco use.

A clearly stated government ‘end’ target date within a maximum of two decades.

Thompson et al. Tobacco Control (in press)

Endgame as a strategy

A deliberate planned strategy of interventions to achieve endgame goals for tobacco use e.g. • Combinations of established (e.g. price, mass media)

and new (e.g. plain packs, supply restrictions) tobacco control interventions

• Over-arching intervention strategies e.g. sinking lid, regulated market model

Structure

What do we mean by tobacco controlled? Achieving the vision

• It is possible!• Some challenges• Some thoughts about the how?


Successful endgame solutions

CFCs Leaded petrol Asbestos Infectious disease eradication (smallpox etc)

Population support for the endgame

0

10

20

30

40

50

60

70

All Māori Pacific

% s

up

po

rt

Agree

Disagree

Source: HSC 2008 Health and Lifestyles Survey Thomson et al. N Z Med J. 2010;123(1308):106-111.

Support for an end of tobacco sales within 10 years

Smoker support for the endgame

0 10 20 30 40 50 60 70 80

Regulating tobaccocompanies more tightly

Government doing more totackle the harm done by

smoking

Increasing the tax ontobacco**

Government setting a dateto ban cigarette sales in 10

years time*

% Support

Maori European/Other

Source: Edwards et al NZ Med J 2009

Daring to Dream: vision is compelling

Participants in daring to dream were presented with a vision of a tobacco free future where children were protected from seeing smoking as a normal behaviour, had virtually no access to tobacco and hence minimal risk of becoming smokers and being exposed to tobacco smoke.

“I think the vision is very good because it …, it makes you stop as a parent and a grandparent and think what the hell are we doing for our kids” – Policy official

Edwards et al. BMC Public Health 2011, 11:580

Young smoker responses to Smokefree 2025 goal

“This is awesome…This makes me feel really proud to be a New Zealander”

Hoek, Maubach et al. Unpublished data.

“I reckon it’s pretty cool. I don’t want to be a smoker in fifteen years.”

“.. it would be something that would be amazing, but I don’t know how possible it would be.”

“2025 ….[pause] am I allowed to swear? [laughs] in your fucking dreams.”

“I’ll be really pissed off when they make it smokefree and I can’t buy cigarettes any more. At least for the first two weeks .. but in the long run, I think smoking is something our country can do without.”

Smoking among doctors and nurses (NZ), 1976-2006

Edwards et al NZMJ 2008; 12: 43-51

Some other occupations (NZ)Occupation 2006 Prevalence

(1981 Census)Dieticians 3.1% (21.2%)

Secondary teachers 7.6% (17.2%)

Ministers of religion 2.7% (8.9%)

Mathematicians and statisticians 4.1% (12%)

Dentists 5.1% (18%)

Structure



Means and ends Another (even bigger) challenge Conclusions

Challenges

The numbers game - need for mass cessation quickly

Continuing disparities in smoking Shifting patterns of smoking uptake New beliefs, behaviours and influences Lack of ‘proof’ for policy and population-

based approaches Tobacco industry

Interplay of cessation and uptake changes

Source: Gartner et al. Tobacco Control 2009; 18: 183-189.

Challenges

Need for mass cessation quickly Continuing disparities in smoking Shifting patterns of smoking uptake New beliefs, behaviours and influences Lack of ‘proof’ for policy and population-


Adult smoking by ethnic group (NZ)

05

1015202530354045

Asian European Pacific Maori

%

Census 2006 NZHS 2006/07

Adult smoking by deprivation (Census 2006 data, Ponniah et al NZ Med J)

0

5

10

15

20

25

30

35

40

1 2 3 4 5 6 7 8 9 10

Decile (NZDep2006)

%

Disparities in smoking by occupation: NZ 2006 census

Doctors 3.6% Hospital orderlies 27.6%

Nurses 14.2% Nurse aides 23.5%

Secondary teachers 7.6%

Teacher aides 19.5%

Kōhanga Reo teachers 41.2%

Challenges



Regular smoking by Year 10 female students, 1999-2010 (NZ)

Source: ASH NZ. National Year 10 ASH Snapshot Survey, 1999-2010

Prevalence of current/regular smokers (%), by age group: Census 2006 compared with NZTUS 2006

0%

5%

10%

15%

20%

25%

30%

35%

15-19 years 20-24 years 25-29 years 30-39 years 40-49 years 50-59 years 60-64 years 15-64 years

age group

percentage

Census NZTUS

Source: Statistics New Zealand; NZTUS 2006

28

Smoking among young people in 1996 and 2006 census

17.7

48.9

28.5

50.3

27.6

35.6

16.3

36.1

0

10

20

30

40

50

60

Māori Non-Māori Māori Non-Māori

15-19yrs 20-24yrs

% R

egul

ar s

mok

ers

1996

2006

Shifting uptake results in new challenges

Challenges of preventing uptake in young adults• Lack of research on preventive interventions• Dispersed settings and social networks (c.f.

school)• Increased autonomy• New beliefs about smoking and smoking –related

behaviours and determinants• Legality of purchase and use (different ethical and

moral framework to justify interventions)

Challenges



New smoking beliefs and behaviours – social smokers

‘I smoke but I am not a smoker’: Phantom smokers (Choi et al. J Am Coll Health 2010: 59: 117-125)• survey of 899 US students (17-25 years). 15.6%

identified as smokers but 45% smoked

New smoking beliefs and behaviours – social smokers (2)

Social smokers differentiate themselves from ‘addicted smokers’:

“I’ve never actually had a cigarette when I I’m just by myself … so I don’t see myself as a smoker, but I see myself as a social smoker … they’re almost mutually exclusive.”

Hoek ,J et al (under review, Tobacco Control)

“Well I actually gave up..in October last year. So I haven’t had a smoke for almost [hesitation] ...I’ve had the odd smoke but I haven’t been a fulltime smoker for almost 12 months ...I might have like one a fortnight, or if I’m having a drink and it’s been a stressful day then I’ll have one but..if I um..if I feel I need one I’ll have one, but other than that I don’t (be)cause I’ve beaten the addiction.”

Ferry, B. Draft MPH dissertation.

New smoking influences – late uptake smokers

“Yip and that’s where I started cause my work mate smoked. Oh he was always offering me one so yeah ...Oh it just gradually built up (laughs). Say we’re doing jobs together and he’d offer me a..and I’d say na..oh the first couple of times..and he’d say..he’d keep on offering and I said ‘why not?’ ..and then..yeah” ‘Peter’

“Oh it was quite horrible really when I think back. Um we were all smokers, we all smoked inside....that’s just what we did...it was a student flat, .. it was a horrible house so we just didn’t really care. ..it was easy to get home and sit down to start with and they’re smoking so you’re like ‘Oh well I might as well have one.’ ” ‘Michelle’Ferry, B. Draft MPH dissertation.

New smoking behaviours – the role of alcohol

NZ ITC study:% Hazardous drinking

(AUDIT >=8)All smokers 33.1%18-24yrs smokers 59.0%Māori smokers 42.1%Pacific smokers 52.1%

Wilson et al. In press NZMJ.

All participants in NZHS – 13.1%

New smoking behaviours – the role of alcohol (2)

Social smokers often only smoke when drinking:

“When I’m drunk, I guess … the care factor goes down … goes down to zero … like who cares about smoking?”

“I just don’t have any cravings unless … I’m out having a few drinks and then I do feel like one…”

“… some nights I can smoke 14 or 15 ciggies or a pack while I am drinking, but I can never do that without alcohol”.

Hoek et al (under review, Tobacco Control)

“I can smoke a whole packet in one night drinking and not have to smoke for two or three days afterwards ….. Yeah I think it’s just social smoking … I think heaps of people are like that…” (Māori female)

“ Well there’s smoke and there’s drink … They’re husband and wife aye.“(19 year old Pacific man)

Glover et al. WhyKwit. Auckland University, 2010

New smoking behaviours – the role of alcohol (3)

Drinking undermines quitting:

“That’s the other thing. You quit and then you drink. You’re used to the habit of having a smoke when you drink. Even when you’re not smoking it goes hand in hand….Oh, a smoke when you drink – just to kick in the buzz.”

Pacific Male smoker Glover et al. WhyKwit. Auckland University, 2010

The role of alcohol – experimental evidence

Diary study with 74 smokers – alcohol use predicted smoking and was associated with urges to smoke and getting a ‘rush’ from smoking.

Piasecki et al Psych Add Behav 2008; 22: 230-239.

Expectation of alcohol increased positive effects of smoking (satisfaction, calming, taste) and administration of alcohol increased smoking and reduced nausea from smoking among 19 young adult experimental smokers.

McKee et al. Psychopharmacology 2010; 210: 355-364.

New smoking behaviours – challenges for tobacco control

• Health education and cessation messages may be ignored by social smokers who do not identify as smokers

• Young adults may respond to different smokefree messaging (and media)

• New interventions needed in settings where smoking occurs: college, workplace, bars etc

• Establishing new social norms about unacceptability of offering cigarettes to new smokers and quitters

• Interventions may be undermined by alcohol and co-intervention may be required

Challenges

Need for mass cessation quickly Continuing disparities in smoking Shifting patterns of smoking uptake New behaviours and influences Lack of ‘proof’ for policy and population-


Lack of ‘proof’ for policy and population-based approaches

Where’s the evidence? – frequent argument of tobacco control opponents and policy-makers

Evidence-base is often limited and difficult to ‘prove’ impact of policy interventions

Evidence base – point of sale

Peer-reviewed evidence (2009):• Observational studies, most cross-sectional, ?

generalisable• Experimental studies limited e.g. exposure and

setting, outcome measures, generalisability etc• Self-reports in surveys and qualitative studies –

limited by possible social desirability etc biases• No published evidence from jurisdictions with

PoS bans

Why the lack of evidence?

Lack of priority and funding for evaluation Methodological difficulties e.g.

• Lack of comparison groups• Lack of control over intervention implementation• Confounding interventions and influences• Lack of data to assess prior trends and long-term

outcomes Novel interventions

Challenges

Need for mass cessation quickly Continuing disparities in smoking Shifting patterns of smoking uptake New behaviours and influences Lack of ‘proof’ for policy and population-


Tobacco industry Arguments

• Interventions don’t work (lack of evidence)• Interventions infringe personal liberty (freedom to choose, nanny

state, slippery slope, commercial freedom, legal product etc etc)• Interventions will have disastrous economic and other unintended

effects Tactics

• Legal challenge, PR and advocacy, lobbying, trade agreements, funds for research and ‘science’ etc etc

Continued marketing• Promotion, price, product (modification), place/accessibility,

Introducing HPP

“… the primary health argument has been lost. There is no way any feasible case can be argued in medical terms….The only way that the right to smoke can be defended is to link it up with the freedom of lifestyle position and with the broader libertarian critique of “health fascism” and the paternalism and authoritarianism of the medical establishment… We have to shift the focus of the debate from the enemy’s strong ground – health – to our strong ground – freedom of choice and individual liberty.”

From Forest’s future strategy: A discussion. Chris Tame, 1989.

Framing the discourse: portray tobacco control advocates and policies as authoritarian

Introducing HPP

Framing: association of smoking with female emancipation

Link tobacco products with cataclysmic and iconic events: Fall of the Berlin wall

“Test the West”

A boy with a West-West shirt on distributes packs of cigarettes to a East German motorcyclist at the West German checkpoint Helmstedt, Nov. 10, 1989.

Structure



Means and ends Another (even bigger) challenge Conclusions

Some thoughts about the how?

Population vs individual cessation approaches Which methods? Some building blocks for success

Non-smokers Smokers Quit

attemptsInitial

success

Assisted

Unassisted

Long term success

Individual cessation approaches Relapse

Non-smokers Smokers Quit

attemptsInitial

success

Assisted

Unassisted

RelapsePopulation-based approaches

PriceMass mediaMarketing controlsProduct modificationCessation availabilityAccessibilitySmokefree policies

Population approaches vs individual cessation

Modelling study of impact on US smoking prevalence (2020):Current 19.8%Doubling quit attempts 13.9%Doubling treatment effectiveness 15.9%Doubling treatment use 16.7%

Levy et al. AJPH 2010, 100: 1253-1259.

Impacts on population quit rates in New Zealand

Population quit rate (%)

% increase in quit rate

Baseline 1.95 0Quit attempt rate 2.15 10Proportion assisted 1.99 1.8Assisted RR 2.02 3.6Unassisted success 2.15 10Relapse 2.13 9.2

Impact of 10% relative change in each parameterFormula from : Tobias et al. AJPH 100: 1274-1281.


Population vs individual cessation approaches Which methods? Some building blocks for success

What methods?

Price/tax increase (duty free) Mass media (campaigns, GHWs etc) Cessation support (treatments, availability etc) Tobacco marketing controls (plain packs, PoS etc) Smokefree policies (bars, cars, outdoors, etc) Product labelling and modification Reducing accessibility/supply (e.g. retail sector,

smuggling) Etc

Five points about methods

Intensification is essential Individual smoking cessation support vs

population based measures Evidence-based as possible Focus on methods for high prevalence groups Consider additional strategies

Priority areas for new research and testing interventions

Retail interventions (beyond PoS and minor access)

Product labelling and modification• Mandated additive disclosure• Harm reduction approaches (safer cigarette)• Nicotine reduction• Additive removal

Possible retail interventions• Sales to minors

• Sales/use ban, education of retailers, test purchases, public education

• Sales staff > 18 years, > 18 years only customers in tobacco shops

• Marketing and counter marketing• Warning signs• Ban PoS displays and ads

• Licensing• Mandatory license lost if

conditions breached • +/- Fees/auctions for licenses(or

incentives not to stock tobacco)• +/- Community control• +/- Restrictions on

numbers/density/moratorium on new licenses

• Accessibility• Restrict number/density of outlets e.g min

distance between outlets, max density, opening hours

• Restrict proximity (e.g. to schools)• Restrict type of venue/retailers (e.g. no

events where >xx% underage, no venues where alcohol sold/consumed, specialist tobacconists only, no mobile sales)

• Others• Mandate NRT etc sales + cessation

support info available• Mandate provision of sales data, tobacco

industry communications• Government retail monopolies• Minimum price controls• Max purchase per day• License smokers

Population support for retail interventions

Source: HSC 2008 Health and Lifestyles Survey Thomson et al. N Z Med J. 2010;123(1308):106-111.

66% agree, 20% disagree with reducing number of retailers that can sell tobacco

Smoker support for retailer restrictions

Agree or strongly agree that tobacco products should only be sold in special places where children are not allowed to go:

Maori - 67%; European/other - 59%

Edwards R, Wilson N, Thomson G, et al.. N Z Med J 2009;122: 1307.

Endgame – overarching strategies

May be needed to achieve endgame goals within reasonable timeframe

Examples:• Regulation of nicotine content• Rapidly escalating tax and duty on tobacco products• Progressive increase in legal age of purchase for next generation• Progressive reduction in retail supply

• ‘Sinking lid’ on tobacco imports• Structural changes to tobacco market (e.g. regulated market model)

Sinking Lid + Adjunct timing/phasing10% absolute reduction in tobacco products

released for sale per year

2010 2012 2014 2016 2018 2020

To

bacco

Im

po

rts

Massive cessation support, mass media + 90% health warnings

Display free stores; Plain packaging; no duty free

Licensing retailers; reducing license numbers

Alternative nicotine delivery systems

Altering tobacco (e.g. zero nicotine cig.)

Thomson et al. Tobacco Control 2010; 19: 431-435


Population vs individual cessation approaches What methods? Some building blocks for success

Building block 1: Ongoing generation and use of evidence

Generate, disseminate and use evidence of effectiveness at population level and for impact on priority populations

Systematic evaluation culture Ongoing research to identify and scope new challenges and

issues Monitoring of progress at population level, including:

• Overarching key markers of denormalisation and social norms (e.g. Chapman and Freeman, Tob Control 2008; 17: 25-31)

• Population quitting tendency (e.g. Tang et al. - Tob Control 2010; 19: S1 56-61.

Evaluation Culture Imperative to carry out thorough evaluation

• Dearth of evidence (used by opponents)• Good practice

Evaluation should be:• Planned• Informed by theory and previous data/literature• Multi-faceted (methods, populations, settings) and

rigorous• Adequately resourced

Scottish SF Legislation1. Semple S,, et al. Bar workers' exposure to second-hand smoke: the effect of Scottish smoke-free legislation on occupational exposure. Ann. Occup. Hyg.

2007;51(7):571.2. Semple S, et al. Secondhand smoke levels in Scottish pubs: the effect of smoke-free legislation. Tob. Control 2007;16(2):127.3. Richmond L, et alI. Impact of socioeconomic deprivation and type of facility on perceptions of the Scottish smoke-free legislation. J. Public Health

2007;29(4):376.4. Phillips R, et al. Smoking in the home after the smoke-free legislation in Scotland: qualitative study. BMJ 2007;335(7619):553.5. Pell JP, et al. Smoke-free legislation and hospitalizations for acute coronary syndrome. N. Engl. J. Med. 2008;359(5):482-91.6. Pell JP, Haw S. The triumph of national smoke-free legislation. Heart 2009;95(17):1377.7. Pell J, et al. Secondhand smoke exposure and survival following acute coronary syndrome: prospective cohort study of 1261 consecutive admissions

among never-smokers. Heart 2009;95(17):1415. .8. Pell J et al. Smoking Ban Significantly Reduces Acute Coronary Syndrome Admissions. JCOM 2008;15(10).9. Mackay D, et al. Smoke-free legislation and hospitalizations for childhood asthma. N. Engl. J. Med. 2010;363(12):1139-45.10. Lewis SA, et al. The impact of the 2006 Scottish smoke-free legislation on sales of nicotine replacement therapy. Nicotine & tobacco research

2008;10(12):1789.11. Hyland A, et al. The impact of smokefree legislation in Scotland: results from the Scottish ITC Scotland/UK longitudinal surveys. The European Journal

of Public Health 2009;19(2):198.12. Hilton S, et al. Expectations and changing attitudes of bar workers before and after the implementation of smoke-free legislation in Scotland. BMC

Public Health 2007;7(1):206.13. Heim D, et al. Public health or social impacts? A qualitative analysis of attitudes toward the smoke-free legislation in Scotland. Nicotine & tobacco

research 2009;11(12):1424.14. Haw SJ,et al. Legislation on smoking in enclosed public places in Scotland: how will we evaluate the impact? J. Public Health 2006;28(1):24.15. Haw SJ, Gruer L. Research: Changes in exposure of adult non-smokers to secondhand smoke after implementation of smoke-free legislation in

Scotland: national cross sectional survey. BMJ 2007;335:549.16. Haw SJ, Gruer L. Changes in exposure of adult non-smokers to secondhand smoke after implementation of smoke-free legislation in Scotland:

national cross sectional survey. BMJ 2007;335(7619):549.17. Goodman PG, et al. Are there health benefits associated with comprehensive smoke-free laws. International Journal of Public Health 2009;54(6):367-

78.18. Fowkes FJI, et al. Scottish smoke free legislation and trends in smoking cessation. Addiction 2008;103(11):1888-95.

Building block 2: Visions, framing and tactics

Need cast iron case and rationale for radical tobacco control measures.

Develop and promote a credible and inspiring vision.

Identify leaders who can communicate and advocate for the vision.

Pay careful attention to advocacy tactics and framing - danger of creating stigma and portrayal as paternalistic, authoritarian etc.

Building block 2: Visions, framing and the case for action





The Moral Case for Intervention

1. Smoking is a uniquely hazardous consumer product2. Most smokers start young3. Hardly anyone starts smoking as a mature adult4. Most smokers want to quit5. Smoking is highly addictive6. Stopping smoking is very difficult (and the methods to help are

not very effective)7. Almost all smokers regret starting8. Virtually all smokers don’t want their children to start smoking9. Smoking causes and exacerbates health inequalities and

poverty10. Secondhand smoke harms non-smokers, including children

Exploring an oxymoron: Smoking as an 'informed choice'

Combined qualitative and quantitative exploration of informed choice among young adult smokers:• Knowledge of smoking’s addictiveness and range of health risks

of smoking• Estimates of likelihood of addiction, continued smoking and

health risks (? optimism bias)• Beliefs about value of later life (? degree of discounting,

telescoping)• Circumstances of onset of smoking experimentation and

becoming a regular smoker (social pressures, alcohol) and impact of knowledge and understanding of risk

Compare findings with tobacco industry arguments

Building block 2: Visions, framing and the case for action





Head to headThomson G, et al. Should smoking in outside

public spaces be banned? Yes. BMJ 2008;337:a2806

VsChapman S. Should smoking in outside public spaces be banned? No. BMJ 2008; 337:a2804

Smokefree Parks in New Zealand

Stigmatisation and the experience of stigma

Tatton L. Smoker stigmatisation: an unintended consequence of smoking denormalisation. Univ of Otago.McCool J et al. Defending the absurd: interpretations of smokers and smoking. Unpublished paper.

“They think we smell. They try and preach to you. It is really frustrating and annoying.”

“God they’re a pain in the ass. They keep ranting and ranting about the bad things of smoking .. the smell of it. If they don’t like it they can go away.”

“She called me a disgusting creature …”

“It does smell really bad, you do the whole kind of wee bit of a cough as you walk past. Just to make sure that they know that you don’t really approve of it.”

Smokers are always pushed out into the outside, away from the non-smokers … it makes you feel .. like the odd one out.”

They just try and make you feel .. Guilty .. And crap about it… It just makes me want to go and have a cigarette [laughs] .. Just to spite them.”

Means as well as ends are important

Means matter in public health and health promotion

Bottom-up, broadly-supported, fully debated measures more acceptable, empowering and sustainable

Hard won gains may be a blessing

The Ottawa Charter for Health Promotion (1986)

Build public policies which support health Create supportive environments Strengthen community action Develop personal skills (empowerment) Re-orientate health services

Means as well as ends are important

Means matter in public health and health promotion

Bottom-up, broadly-supported, fully debated measures more acceptable and sustainable

Hard won gains may be a blessing

Structure




Deprivation profile of the European and Other ethnic groups

1 = least deprived 10 = most deprived

0

50000

100000

150000

200000

250000

300000

350000

400000

1 2 3 4 5 6 7 8 9 10

NZDep96 index of deprivation

Usually resident

population

Deprivation profile of the Maori ethnic group


0

20000

40000

60000

80000

100000

120000

140000

160000

1 2 3 4 5 6 7 8 9 10


Usually resident

population

Deprivation profile of the Pacific Island ethnic group


0

10000

20000

30000

40000

50000

60000

70000

1 2 3 4 5 6 7 8 9 10


Usually resident

population

Can the endgame be achieved for all without addressing broader structural determinants?

Achieving mass cessation in high prevalence groups is a huge challenge

Danger of achieving the endgame only for some and persisting smoking viewed as a problem for a marginalised section of society – which can be ignored.

Structure




Questions for you What might the vision or endgame scenario look like for you? What measures will work in your setting? How can you ensure that the endgame vision is

communicated to all sections of the community and key stakeholders?

How can you make the paradigm shift, develop a credible and inspiring vision and strategy, and achieve your endgame?

How can you ensure that you are part of the movement for wider change to achieve broader public health goals and social justice?

Kia oraThank you

Tobacco controlled – what will it take? Oceania Tobacco Control, Brisbane October 2011 Richard...

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