Tobacco control in Australia



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Australia:

the healthiest country by 2020

Technical Report 2
Tobacco control in Australia: making smoking history

Including addendum for October 2008 to June 2009



Prepared for the National Preventative Health Taskforce
by the Tobacco Working Group

Australia: the healthiest country by 2020.

Technical Report No 2

Tobacco control in Australia: making smoking history

Including addendum for October 2008 to June 2009
ISBN: 1-74186-929-3

Online ISBN: 1-74186-930-7

Publications Approval Number- P3-5459

Paper-based publications

(c) Commonwealth of Australia 2009

This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Commonwealth. Requests and inquiries concerning reproduction and rights should be addressed to the Commonwealth Copyright Administration, Attorney-General’s Department, Robert Garran Offices, National Circuit, Barton ACT 2600 or posted at http://www.ag.gov.au/cca

Internet sites

This work is copyright. You may download, display, print and reproduce this material in unaltered form only (retaining this notice) for your personal, non-commercial use or use within your organisation. Apart from any use as permitted under the Copyright Act 1968, all other rights are reserved. Requests and inquiries concerning reproduction and rights should be addressed to Commonwealth Copyright Administration, Attorney-General’s Department, Robert Garran Offices, National Circuit, Barton ACT 2600 or posted at http://www.ag.gov.au/cca
Acknowledgements

The Technical Report on tobacco was prepared on behalf of the National Preventative Health Taskforce:

Professor Rob Moodie, Chair

Professor Mike Daube, Deputy Chair

Ms Kate Carnell AO

Dr Christine Connors

Dr Shaun Larkin

Dr Lyn Roberts AM

Professor Leonie Segal

Dr Linda Selvey

Professor Paul Zimmet AO



The report was prepared with advice from the following members of the National Preventative Health Taskforce Tobacco Working Group:

Professor Mike Daube, Chair

Ms Viki Briggs

Professor Simon Chapman

Dr Christine Connors

Dr Shaun Larkin

Ms Kate Purcell

Dr Lyn Roberts AM

Ms Denise Sullivan

Professor Melanie Wakefield

Ms Michelle Scollo – writer

The contributions made by Ms Meriel Schultz, Adviser, National Preventative Health Taskforce and the Department’s Population Health Strategy Unit, Publications Unit and Communications Branch are gratefully acknowledged.

Contents
Overview and summary of action proposed v

Summary of proposed measures vii

Revenue measures that would reduce the affordability of tobacco products vii

Legislative reforms to address current deficiencies in tobacco regulation vii

Expenditure measures vii

Campaigns vii

Indigenous tobacco control vii

Other initiatives to reduce social disparities in smoking viii

Health system interventions viii



Reinvigoration of the Australian National Tobacco Strategy viii

Overseas development ix


1 Introduction: the big picture 1
2 Progress in meeting National Tobacco Strategy objectives: trends and concerns 5

2.1 Uptake of smoking 5



2.2 Smoking rates among adults 7

2.3 Exposure to tobacco smoke among non-smokers 11
3 Progress in Australia on recommended policies and programs 14

3.1 Regulate 16

3.1.1 Price through tax 16

3.1.2 Place of use 20

3.1.3 Place of sale 21



3.1.4 Promotion 22

Promotion through new media and events 22

Smoking in movies, TV programs, magazines and electronic games 23

Promotion through packaging 24

3.1.5 Product information for consumers 25

Health warnings 25

Ingredients disclosure 27



Display of tar, CO & nicotine yields 28

3.1.6 Product 28



Cigarette ingredients, design and toxicity 28

Oral tobacco 30



Alternative nicotine delivery devices 30

3.1.7 Producers and purveyors 31

Licensing of retailers 31

Licensing of manufacturers 32



3.2 Public education: Increase promotion of Quit and smoke-free messages 34

3.3 Improve services and treatment for smokers 40

3.3.1 Therapies that increase success rates 40

3.3.2 Systems for delivering therapies 41

3.4 Better support families and educators 45

3.5 Tailor messages and services for highly disadvantaged groups 47

3.5.1 Indigenous Australians 47

3.5.2 Pregnant women from Indigenous and other disadvantaged groups 49

3.5.3 Non-English-speaking people 50

3.5.4 The mentally ill 51

3.5.5 Prisoners 52

3.5.6 The homeless 52



3.5.7 Highly disadvantaged neighbourhoods 53

3.6 Address causes of disadvantage 55

3.6.1 Social inclusion 55



3.6.2 Investing in tobacco control as a component of social development 56

3.7 Improve focus in research, monitoring and evaluation 58
4 What next, what first and for what cost? 59
Major sources used in this document 60
References 61
Addendum for October 2008 to June 2009 92
Overview and summary of action proposed

Between 1950 – when clear evidence on the dangers of tobacco became available[1, 2] – and 2008, almost 60 years later, more than 900,000 Australians died prematurely because they smoked.[3]

The Australian death toll caused by smoking will pass the million mark within the next decade. The social costs of tobacco exceeded $31 billion in 2005,[4] but it is impossible to put a value on the grief suffered by the hundreds of thousands of families who have lost a child, a spouse or a parent in what should have been the most productive and rewarding years of their life.

Projections based on current patterns of uptake and quitting suggest that on our current course, prevalence of daily smoking will still be over 14% in 2020 and will remain close to 10% well past the year 2070.[5]

Given the scale of death, disease and disability caused, and with an extensive body of evidence now providing clear guidance on effective ways to reduce smoking, both at the population level and in clinical settings, it is simply not acceptable to allow the tobacco epidemic to continue for another 60 years.

Following the adoption of an international Framework Convention on Tobacco Control in 2003,[6] governments around the world are moving quickly to strengthen policies to discourage smoking. Each week, the benchmark changes, with countries and states rapidly copying each other in an accelerating series of ‘catch ups’. If we want to reduce smoking to the greatest extent and as soon as possible, we should move to international best practice in all aspects of tobacco control policy.

The Tobacco Working Group of the Preventative Health Taskforce believes that if prevalence of daily smoking were to reduce to 9% or less by 2020, smoking would continue to decline until rates were so low that it would no longer be one of our most important health problems. Achieving this target will require a dramatic reduction in the numbers of children taking up smoking and a doubling of the percentage of smokers who are trying to quit.

Australia’s record over the past 30 years has been impressive, but over the past six years we have taken our foot off the accelerator pedal in several areas of tobacco control. Research and international experience indicate the need for sustained effort: there is no cruise control switch. Unless we make tobacco products much less affordable, commit to providing commercially realistic funding for media campaigns not just in some years but every year, ban all remaining forms of promotion and provide greater help for smokers trying to quit, reductions in tobacco use in Australia could easily stall.

This paper presents the latest data on smoking in Australia. Building on extensive information compiled in the National Tobacco Strategy document released in 2004,[7] it provides an update of research available since that time, and describes what has been done over the past four years and where Australia falls short of international best practice.

Crucially, this paper sets out what needs to be done next.

Most importantly, we need to increase taxes on tobacco products, invest more funds in media campaigns and implement other policies that are known to be highly effective, all of which could be done with a net positive increase in government revenue.

The paper also suggests the policies and programs that, in combination, would institutionalise the treatment of tobacco dependence in Australia’s healthcare system, recognising that the cost-effectiveness of treating tobacco dependence compares very favourably with other medical interventions.

Finally, we propose something that has not yet been tried anywhere in the world, but which would cost the taxpayer nothing and offers the prospect of shattering the image of cigarettes as an ordinary consumer item. If we act quickly, Australia can overtake the British Government and become the first country in the world to mandate that cigarettes be sold in plain packaging. There is good evidence that this would have a profound effect on young image-conscious teenagers.

If the proposals outlined in this paper are pursued, in addition to dramatically reducing the numbers of people who smoke, we would move to a point where cigarettes are rarely supplied to children, and non-smokers are almost never exposed to second-hand smoke.

The paper argues that a piecemeal approach to tobacco control will be much less effective than a comprehensive one, with a higher likelihood of unintended consequences.

Action in all seven of the areas described in this document could – even within our lifetimes – make


smoking history.

Summary of proposed measures

An overall target of at least one million fewer Australians smoking by the year 2020 (no more than 9% of people aged 14 and over).

Revenue measures that would reduce the affordability of tobacco products

1. Increase excise and customs duty on tobacco to discourage smoking and to provide funding for prevention activities, including those in lower socio-economic status groups.

2. Amend customs and excise legislation to implement measures to prevent erosion of prices through the evasion of duties on tobacco.

Legislative reforms to address current deficiencies in tobacco regulation

3. Mandate plain packaging of cigarettes and increase the required size of graphic health warnings to take up at least 90% of the front and 100% of the back of the pack.

4. Modernise the Tobacco Advertising Prohibition Act 1992 (Cth) to cover new forms of media and to ban internet sales, tobacco displays at point of sale, payments to retailers and proprietors of hospitality venues, and public relations activities including promotion of corporate image and ‘corporate responsibility’ donations.

5. Establish a national system to more regularly review mandated warnings and to warn smokers of emerging and new evidence about health effects in a more timely and systematic manner.

6. Establish or nominate a regulatory body with the powers to ban, limit or mandate tobacco product constituents, emissions, additives or design features.

7. Strengthen state and territory legislation to ensure that cigarettes are not sold to children.

8. Extend state and territory laws that protect against exposure to second-hand smoke.

Expenditure measures



Campaigns

9. Provide commercially realistic funding over a period of several years for a continuing social marketing campaign to be developed by an expert group and run in collaboration with state Quit agencies.

This would include an Indigenous component and research to help maximise impact with lower socio-economic status groups. Funding would need to be sufficient – at least $43 million per annum – to ensure television advertising at levels known to be effective (at least 700 Television Audience Rating Points in every jurisdiction each month) and sufficient to produce creative material for all the major messages (health effects, personal consequences etc) that need to be covered. To complement and enhance the credibility of paid advertising, funding should also cover an advocacy project to alert and assist journalists to report more of the research published each week on the health effects of smoking.

Indigenous tobacco control

10. In addition to the measures included in 9 above and 11 below, fund:

advocacy training and mentoring for people working in Indigenous tobacco control

Indigenous Tobacco Control Workers in each state and territory affiliate of NACCHO, the National Aboriginal Community Controlled Health Organisation

incentives to encourage non-government agencies to employ Indigenous workers to improve Indigenous-specific programs

appropriately designed training that is realistic and empowering for health workers

a trial of multi-component community-based programs in three sites (urban, rural and remote) to deliver locally managed interventions.

Other initiatives to reduce social disparities in smoking

11. Establish initiatives to tailor services for Indigenous smokers and for other highly disadvantaged groups unable to be reached by mainstream services. These would include:

telephone call-back services available to pregnant smokers, to Indigenous and to non-English-speaking smokers in any state or territory, delivered by staff experienced in working with each group

resources for professionals to encourage and assist smokers in psychiatric and correctional facilities.

12. Implement programs to subsidise nicotine replacement therapy (NRT) for people who are homeless and other highly disadvantaged people in financial stress, for patients of mental health services, for clients of juvenile justice and correctional services, and for callers to the Quitline.

13. Implement a pilot campaign including outdoor advertising and other initiatives to boost the use of cessation products and services in disadvantaged areas.

14. Trial ‘payment for performance for patients’ (P4P4P) schemes in highly disadvantaged communities.

Health system interventions

15. Include in healthcare agreements between the Australian Government and states and territories requirements to:



provide extended-hours Quitline and call-back services

ensure that all government-funded organisations and services are smoke-free

ensure that all health and human services (community health centres, maternal and child health services, drug treatment agencies, mental health services and hospitals etc) routinely identify patients who smoke, advise such patients to quit, provide them with NRT and where appropriate refer them to the Quitline.

16. Develop national resources to provide training to professional staff working in private health and medical practices, and in all healthcare services and institutions.

Reinvigoration of the Australian National Tobacco Strategy

17. To reinvigorate Australia’s comprehensive National Tobacco Strategy:



update (but do not waste time and money redrafting) the Strategy[7] and supporting documents,[8-14] and encourage more effective use of these by the tobacco control field

promote the relevance of the Strategy for achieving the Australian Government’s broader objectives of reducing the costs of chronic disease, improving workforce productivity, achieving greater social inclusion and contributing to social development, both in Australia and in developing countries.

Overseas development

18. Australia could use its expertise in both the legislative and policy spheres in tobacco control to encourage recipients of overseas aid to adopt strong tobacco control measures as a component of economic and social development. Such a focus would help to amplify Australia’s contribution to the achievement of millennium goals to an extent well in excess of what is achievable through its monetary contribution alone.
1. Introduction: the big picture

Smoking continues to be Australia’s largest preventable cause of death and disease. Over three million people – just under 18% of Australians aged 14 years and over – still smoke at least weekly.[15] About half of the smokers who continue to smoke for a prolonged period will die early, half of them in middle age[16] when children and grandchildren depend on them, and while they are in the most productive years of their working lives.[17] Tobacco use caused 15,511 deaths in 2003,[18, 19] and cost the Australian community around $31.5 billion in 2004–2005.1 [4] Smoking is responsible for 12% of the total burden of disease and 20% of deaths in Indigenous Australians.[20]

Goal of Australia’s National Tobacco Strategy: To significantly improve health and to reduce the social costs caused by, and the inequity exacerbated by, tobacco in all its forms[7]

Even if the prevalence of smoking were to decline overnight to single-digit figures, the personal and social costs of smoking would continue to be high for many years, not just because the effects are so long term but also because they are so far-reaching. As noted by Collins and Lapsley, their estimates must considerably understate the true costs of tobacco use, given the numerous items for which there was not yet enough research to enable them to plausibly quantify effects. Current estimates of the costs of smoking are based on assessments of the excess risk of premature birth, cardiovascular disease, respiratory disease and cancers of the respiratory, digestive and reproductive organs.[21]

It is indeed hard to think of an organ of the body to which smoking is not harmful, and scientific studies are published literally every day providing new or strengthened evidence of the impact of smoking on dozens of diseases and conditions, including most of the chronic health problems currently driving exponential growth in spending on hospital, medical and pharmaceutical treatments in this country.2 [22]

Beyond the early deaths, the years of debilitating illness and the costs to the public healthcare system, smoking in Australia also contributes significantly to social disadvantage. Spending on tobacco products causes financial stress.[23] It works against the accumulation of wealth, and helps to perpetuate poverty across the generations.[17, 24] Cigarettes increasingly act as a badge[25] and a marker[26] of low educational aspirations, low socio-economic status and unemployment. Smoking by people from disadvantaged backgrounds may be becoming a barrier to acceptance in more advantaged social networks.[27] Doing more to reduce smoking may thus also support the government’s central policy goals of educational excellence[28] and social inclusion.[29, 30]

While tobacco use seems likely to continue to cascade downwards in the most educated groups, the history of tobacco control in Australia shows that smoking in the population as a whole will not reduce without vigorous and consistent action by governments and health organisations.

After an intial decline in the 1960s, smoking increased again in the early 1970s in response to more agressive marketing by tobacco companies, especially advertising aimed at young women.

In the mid-1990s total spending on media campaigns fell as Quit organisations grappled with budget cuts and simultaneous pressures to develop targeted programs for a growing number of population groups. During this time, cigarettes also became more affordable. After a decade in decline, between 1992 and

1998 the prevalence of smoking among adults flattened. It went into decline again following an increase in media spending and an increase in cigarette taxes in 1999, and the stepping up since 2001 of measures to make public places smoke-free.





Figure 1: Smoking prevalence in adults aged 18+, spending on media campaigns per person $89–90 and costliness of cigarettes, Australia, 1983–2007

Sources: CBRC analysis of National Drug Strategy Household Survey,[31] Average Weekly Earnings compared with recommended price of tobacco products,[24] reports by government and non-government bodies on spending on tobacco control in Australia[32-34]

These observations of trends over the past 30 years are confirmed by a recently published analysis of changes in smoking behaviour in response to changing policy parameters on a month-by-month basis. Increases in the costliness of cigarettes and large increases in television Target Audience Rating Points have exerted powerful effects in reducing smoking in the largest Australian states. When expenditure is low and prices stay the same, smoking prevalence stops falling.[35]

Some places in the world are doing much better than others in reducing smoking. In California (where a long-running, well-funded comprehensive tobacco control program has emphasised the immorality of marketing a deadly product and the unacceptability of smoking around others) and in New York City (which since 2004 has had a massive blitz on smoking, simultaneously hiking taxes on tobacco, banning smoking in all public places, running a large media campaign and promoting free nicotine replacement therapy), use of tobacco has declined at faster rates than in the rest of the country



Some jurisdictions in Australia are also doing better than others at reducing smoking.




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