Fear comes in many forms. At the turn of the 20th century, our grandparents were terrified by tuberculosis and polio (to mention only a few of the hideous communicable diseases that plagued the human race). We pulled out all the stops and gladly spent millions to "conquer" the responsible infective agents, at least in the resource-rich nations. As a result, the "plagues" which now terrorise the industrialised world are cardiovascular disease and cancer. These two categories of disease alone are responsible for a majority of all deaths, illnesses, disabilities and the lion's share of medical care costs. The leading responsible agent for these is tobacco. Yet, we tolerate this agent, subsidise it with government funds, and passively accept the tobacco industry argument that our societal ethos accepts its use (that is, it's "normal" and "expected"), and those who oppose its use are, by implication, "intolerant" and "puritanical". There are few examples of so deadly an error in human history. We need to recognise that this problem is caused by an agent (tobacco) as virulent as the tubercule bacillus or the poliovirus. Furthermore, this agent is being skilfully marketed by an industry which is, sans hyperbole, an immensely profitable organisation that has grown by strategically buying social and political influence. An egregious example of this is the relationship between the big tobacco lobbyists and most of the major political parties in Australia.1

Tobacco use remains the single largest underlying preventable cause of death in Australia. The tragic irony is that these deaths are so very preventable. Yet tobacco control measures in Australia have stalled, primarily due to a monumental paucity of funds and political will. Sadly, the Australian crusade is actually a non-crusade. Because of complacency, you are falling far short of what could be achieved if you were once again to become global leaders in tobacco control. Needless to say, tobacco companies are constantly and very effectively working behind the scenes to diminish the gains that have been made to date. Tobacco use in Australia will probably fail to decline, and could even increase, unless a proactive campaign to regenerate your flagging efforts is undertaken.

To that end the Cancer Council of New South Wales invited us to visit in November 2002 to transfer some of the California Tobacco Control Program's expertise, irreverence, passion and technology to our Australian counterparts.

From 1988 (the year before the California program was launched) to 2001, annual per capita consumption of cigarettes in California declined by 60% to 50 packs per capita. During the same period, annual per capita consumption in the entire nation (including California) declined by only 34%, to just over 100 packets per capita (twice the rate in California).2 The comparable statistic for Australia is currently derived to be about 75 packs per capita annually. From 1988 to 1997, the decline in lung and bronchial cancer rates in California was five times the rate of the decline in the rest of the nation.3 Furthermore, prevalence rates of youth tobacco use in California declined 47% (from 11.2% in 1997 to 5.9% in 2001).4 What worked in California will also work in Australia.

The California experience demonstrates that a comprehensive approach designed to change social norms and expectations around tobacco use will reduce both its use and tobacco-related morbidity and mortality. This approach involves media-supported advocacy for laws and voluntary policies that discourage tobacco use, especially at the community level. The objective of this approach is to change the social environment in such a way as to make tobacco use less desirable, less acceptable, and less accessible to adults and youth. The four broad priority areas, or policy themes, of the California program are:

• Protecting people from exposure to secondhand tobacco smoke;

• Exposing and countering tobacco industry influences in Californian communities;

• Reducing the availability of tobacco by regulating tobacco retailers; and

• Providing support for smoking cessation services.

Having studied the dynamics of your political and governmental system, we identified four areas for Australia to work on.

Firstly, the insidious influence of the tobacco industry on both sides of your parliamentary aisle is a huge drawback. The fact that a former premier of New South Wales is currently the chairman of your biggest tobacco company says it all.

Secondly, your allocation of funds to tobacco control is ludicrous. Our largest State, California, has spent over US$1 billion in 12 years to achieve these results. In your largest State, New South Wales, you spent less than US$2 million last year.

Thirdly, your governmental bureaucracy needs to be infinitely more agile and aggressive. Throughout our trip, we were complacently assured by government officials that some of these interventions "would not work" in Australia. We used to hear the same arguments in California. We just ignored them and pushed ahead aggressively to become the first major governmental organisation to take this "legally constituted tobacco industry" head on, by publicly ridiculing them for their falsehoods (as to the addictive, atherogenic, mutagenic and carcinogenic properties of tobacco smoke) and questioning their amoral marketing practices. You must give the leaders of your tobacco control program permission to be caustically critical of the tobacco industry and its surrogates as an official government policy.

Lastly, your constituency of anti-tobacco control advocates is too civil by far. Even as we enjoyed success after success, we were continuously and usefully criticised, prodded and even pilloried by an ever-vigilant anti-tobacco constituency to do more and more, to good avail.

In expressing these criticisms, we speak as respectful co-labourers in the field of tobacco control. Our own efforts were inspired by Australia's pioneering initiatives in tobacco control 20 years ago. Australia has had phenomenal success in the implementation of certain measures like advertising bans and point-of-sale restrictions (price and pack warnings being good examples of these), but none of these is a fundamental threat to the operation of the industry. Thus, having seen your once-proud effort diminished considerably, we have ventured to speak frankly in the hope that this may contribute to restoring your tobacco control efforts to their former glory.

Our best advice?

• The allocation of funds to tobacco control in Australia is negligent, bordering on the farcical. At a minimum, you have to spend $50 million per year in New South Wales and well over twice that for all of Australia. This could fund an aggressive tobacco control program capable of producing a sea change in community norms around tobacco use.

• Your focus should be on increasing the tax on all tobacco products, as well as promulgating a total ban on smoking in all indoor venues, including bars, pubs and clubs. Smoking bans are, contrary to the tobacco industry's propaganda, good for health reasons, good for business, and good politics, as has been amply illustrated in California.5-7 A key point to remember is that a good adult campaign is also a good youth campaign.

• There is a clear divide between your political leaders "cosying up to" the tobacco industry and the preferences of your population, as expressed by polling and survey data.8-10 During our visit, we were repeatedly confronted with the question as to why your political leaders were not responding to these expressed needs.

In conclusion, we do not delude ourselves that this will be easy to achieve given the organised opposition of the monolithic tobacco industry behemoth and its front groups and political influence in Australia. However, there is no shortage of anti-tobacco control expertise in Australia, where some of the world's leading tobacco control experts reside. You have the talent and technical expertise for an effective program. So, why are Australian authorities emulating the ostrich and sticking their heads in the sand? The anti-tobacco constituency needs to sound the clarion call: "In tobacco control in Australia: what aren't we doing and why aren't we doing it?".