Key policy priorities in summary
Australia has a strong record of tobacco control and has implemented a number of successful interventions to reduce tobacco use. However, tobacco use remains the leading cause of preventable death in Australia. Further, each year for every smoker who dies prematurely, 30 more smokers will be affected by a disease caused by tobacco use, resulting in disability, pain and suffering, and considerable costs to Australia’s health care system. Total social and economic costs to Australian society in 2015-16 were estimated to total $136.9 m.
A coordinated, multi-strategy approach aimed at reducing the burden of tobacco-related death and disease in Australia is needed. This approach requires action from all levels and sectors of government, as well as non-government, community and health organisations.
To address tobacco control, the World Health Organization has provided a list of ‘best buys’ and other recommended interventions as part of the Global Action Plan for the Prevention and Control of non-communicable diseases 2013-2020. These include:
- Increase excise taxes and prices on tobacco products
- Implement plain/standardised packaging and/or large graphic health warnings on all tobacco packages
- Enact and enforce comprehensive bans on tobacco advertising, promotion and sponsorship
- Eliminate exposure to second-hand tobacco smoke in all indoor workplaces, public places and public transport
- Implement effective mass media anti-smoking campaigns that educate the public about the harms of smoking/tobacco use and second-hand smoke
Australia is either meeting or on track towards global best-practice levels against four out of the five WHO ‘best buys’. Australia’s tobacco tax measures have led to smokers reporting cost as the main reason for quitting. Australia’s advertising restrictions are among some strongest in the world, although the tobacco industry continues to seek opportunities to subvert effective policies in this area. Protections from second-hand smoke in public places continue to be strengthened. Of the five WHO ‘best buys’, Australia is performing most poorly in implementing effective mass media anti-smoking campaigns. Australia’s current underperformance in this area is notable when considered in relation to the nation’s strong track record of effective and cost-effective campaigns. The WHO recommends that high-income countries such as Australia should commit adequate resources to anti-smoking campaigns as a focal point for a comprehensive policy response to tobacco control.
Evidence informing Cancer Council’s recommendations is summarised in the next section.
Reduce smoking prevalence in the general population
Increase investment in mass media antismoking campaigns
At a national level, tobacco excise and mass media antismoking campaigns are the most effective policy interventions to reduce tobacco-related healthcare costs and preventable deaths, particularly when used in tandem. Television-led public education campaigns remain the most efficient media channel for reaching large proportions of the population, with video-based messages, despite changes in media consumption habits among some demographic groups. Even in a modern media landscape, medial channels such as radio and outdoor advertising also provide important supportive channels that serve to boost the reach of public education campaigns.
Over the past decade, investment in mass media antismoking campaigns has declined substantially, paralleling a slowing of reduced smoking prevalence over that period. Reduced investment has occurred at a whole-of-government level. Australian government expenditure on anti-smoking campaigns was almost $36 million in 2010-11. Expenditure then fell by more than 80% in 2013-14 and has remained at $10 million or less annually to 2017-18. Annual federal expenditure on anti-smoking campaigns in 2017-18 was one-fifth of that in 2010-11.
Attitudes and quit behaviour reported through the 2019 National Drug Strategy Household Survey reflect the impact of this substantial reduction in antismoking campaign investment in Australia. In 2019, only 4.7% of smokers reported that seeing antismoking TV advertisements motivated them to change their smoking behaviour (down from 9.2% in 2013).  This lost opportunity is compounded by the failure to gain a synergistic benefit from the recurrent increases in tobacco excise since 2013. Increasing the price of tobacco products is significantly more effective in reducing prevalence if supported by hard-hitting mass media campaigns.
Mass media antismoking campaigns are highly cost-effective. The savings from averted health care costs associated with tobacco control mass media antismoking campaigns significantly exceed campaign costs. However, intensity and duration need to be at evidence-based levels for behaviour change. Campaign exposure is recommended to be between 400 to 700 Target Audience Rating Points (TARPS) per month to motivate quitting behaviours. Currently, exposure to quit messages in Australia is inadequate, falling below the minimum recommended level of 400 TARPS per month. Between 2014 and 2017, federally sponsored mass media antismoking campaigns achieved an average of 540 TARPs per year.
Increasing investment in ongoing television-led public education campaigns to evidence-based levels is needed to ensure that smoking prevalence in Australia continues to decline. Implementing effective mass media antismoking campaigns is one of WHO ‘best buys’ in tobacco control and has been identified as an area where Australia is currently performing most poorly. As a priority area for action, Cancer Council recommends increasing investment in mass media antismoking campaigns to $40 million per year for at least 3 years. This investment is dwarfed by the social and economic costs of smoking estimated to be $136.9 billion in 2015-16  and federal excise revenue. In 2020-21, the projected federal excise revenue is $16.2 billion.
Strengthen efforts to reduce tobacco use in groups with high smoking prevalence
Ensure long-term funding and support for programs and partnerships that reduce tobacco use among Aboriginal and Torres Strait Islander people
High rates of tobacco use are the major contributing factor to the poor health outcomes among Aboriginal and Torres Strait Islander people. Smoking prevalence has decreased over time but remains much higher for Aboriginal and Torres Strait Islander people than other Australians (45% vs. 16%, respectively). It is vital that efforts are directed to accelerate the decline in the prevalence of tobacco use among Aboriginal and Torres Strait Islander people. To do this, substantial long-term investment in activities that are culturally specific such as the Tackling Indigenous Smoking program is required, as well as investment in public education campaigns. Cancer Council supports long-term targeted investment in mainstream tobacco control activities and cessation support as part of routine clinical care.
Cancer Council also supports continued funding of the TV-led public education campaign, Don’t Make Smokes Your Story at recommended exposure levels, in addition to other population-wide campaigns that include Aboriginal and Torres Strait Islander people as a target audience to encourage smoking cessation.
Certain population groups in Australia face circumstances that make it more likely that they will initiate tobacco use and face barriers to quitting. Higher tobacco use contributes to intergenerational poverty and financial deprivation which can prevent people from securing food, accommodation, education, employment, and living a stable and fulfilling life. Population groups with a high smoking prevalence or for whom smoking poses greater than usual health harms are Aboriginal and Torres Strait Islanders, culturally and linguistically diverse populations, pregnant women, single parents, people experiencing homelessness, people with lower socioeconomic status, prison populations, users of other drugs, and lesbian, gay, bisexual, trans, queer and intersex (LGBTQI) people.
Smoking also disproportionately affects the mental and physical health of people with mental health illness. While smoking rates have decreased over time for people with high or very high psychological distress, rates remain much higher than the general population (20.8% vs. 11.6%). Quitting smoking can improve mental health with improvements in depression, anxiety, stress and psychological quality of life. Smoking cessation does not interfere with treatment and can improve treatment outcomes.  It can also result in a reduction in dosage of some medications. People experiencing mental illness are interested in quitting and can do so successfully with the right support. Mental health service providers can play a critical role to support people with mental health issues to quit smoking by providing tailored cessation support and creating supportive smoke-free environments. Cancer Council and the Heart Foundation of Australia recommend that all mental health services provide a supportive smoke-free environment, including smoke-free policies (partial or full bans) and provide cessation support to all clients and staff.
Increasing investment in national TV-led anti-smoking campaigns, improving efforts around cessation and reducing the affordability of tobacco products are recommended interventions to reduce tobacco use among population groups with a high prevalence of tobacco use. Mechanisms must also be established to determine tobacco use and cessation activity among groups with high-prevalence of tobacco use, and to monitor the delivery of evidence-based tobacco dependence treatment in these groups. Cancer Council recommends including a question about tobacco use among Australians aged 15 years and older in the 2026 Census to provide reliable data for monitoring tobacco use among high smoking prevalence groups to guide investment for targeted activities.
Improve the effectiveness of tobacco taxation policy
Reducing the affordability of tobacco products through taxation is the single-most cost-effective way to reduce tobacco use. Australia has adopted a strong policy of tax increases that have been associated with significant declines in tobacco use, particularly among low-income groups. Daily smoking prevalence in Australians aged over 14 has declined from 21% in 2001 to 11% in 2019, and the overall volume of tobacco products sold has also declined. However, tobacco companies are undermining taxation by using strategies such as offering products in a wide array of pack and pouch sizes. This confuses price signals, aggressively promoting cheaper roll-your-own (RYO) tobacco and facilitating sales of discounted tobacco through favourable deals with high-volume retailers.
Tobacco industry marketing of progressively smaller pouch sizes has driven a substantial shift to use of RYO tobacco among price sensitive smokers who would likely otherwise have attempted to quit smoking. Compared to conventional cigarettes, RYO tobacco is subject to lower taxes , which has led to use of RYO tobacco among young people , doubling between 2007 and 2019.The introduction of progressively smaller pouch sizes of RYO at significantly lower retail prices is threatening Australia’s progress in reducing uptake of smoking in young people.  Consistent and proportional greater increases in excise on RYO tobacco are recommended to reduce the disparity in prices of different tobacco products.
Taxation of tobacco products, including federal excise, customs duty and state franchise fees, has been central to tobacco control strategy in Australia. In Australia, excise, customs duty and GST make up around 60% of the retail price of leading brands of cigarettes. The prices of premium cigarette brands in Australia are very high by international standards, Increased taxation of tobacco products has been associated with significant declines in smoking prevalence, especially among disadvantaged populations . Following the annual 12.5% tax rises in 2016 and 2018, tobacco sales in remote Aboriginal communities reduced by 5.8% and 8.2%, respectively. The cost of smoking has been increasingly reported as the leading factor in motivating smokers to quit over the past decade (from 36% in 2007 to 58% in 2019).
In September 2020, the final in a series of 12.5% annual recurrent increases in tobacco excise introduced in 2017 took effect. This series of excise increases follows previous increases in excise and customs duty of 25% in April 2010, and four 12.5% annual increases from 2013-17. While excise on cigarettes has increased substantially over the past decade, investment in mass media antismoking campaigns across all jurisdictions has declined substantially. In 2017-18 annual federal expenditure on antismoking campaigns was just $7.1 million.
The projected income in federal tobacco revenue in Australia for 2020-21 is estimated to be $16.2 billion.  Less than 0.25% of this projected revenue would be sufficient to fund mass media antismoking campaigns at evidence-based levels -that is $40 million per annum. Cancer Council recommends:
- amending the Tobacco Plain Packaging Act 2011 to require packs of cigarettes to be sold only in pack sizes of 20 cigarettes and RYO pouches to be sold in no sizes other than 30 grams.
- amending the Tobacco Advertising Prohibition Act 1992 to end all price-related promotion, including specially, discounting of tobacco products and cushioning of tax increases.
- regularly increasing tobacco customs duty and excise.
- ensuring major investment in national evidence-based mass media antismoking campaigns and evidence-based tobacco dependence treatment.
- any further increase in tobacco excise of 10% or more is accompanied by an investment in national mass media antismoking campaigns to the value of $40 million in the first year of the excise increase.
- harmonising excise and/or customs duty on RYO tobacco further to reduce the disparity in prices between pre-made and RYO cigarette products.
- maintaining strong surveillance, enforcement and fines for growing, manufacturing, importation, distribution and sale of illicit tobacco.
Ensure that evidence-based tobacco dependence treatment is offered to every tobacco user in every appropriate interaction with the health system
The treatment of tobacco dependence in Australia is fragmented and insufficient, which causes inefficiencies, redundancies and wastage in the health system and inadequate support for smokers. There is no endorsed or minimum standard for training or practice for health professionals to provide cessation advice, and no centralised (or routine) monitoring or evaluation of services . Implementing comprehensive and integrated treatment guidelines to promote cessation of tobacco use and adequate treatment for tobacco dependence is needed in Australia to meet our obligations under Article 14 of the Framework Convention of Tobacco Control (FCTC).
Evidence-based tobacco dependence treatment must be embedded and provided as routine care in all health, mental health, and drug and alcohol services in Australia. Combination nicotine replacement therapy (NRT) is nearly four times more effective for quit attempts than using single products alone . Pharmaceutical Benefits Schemes approval of combination NRT should be considered to ensure best practice use is affordable for all Australians. Funding Quitlines to provide free pharmacotherapy at least to high prevalence groups should be considered as it would remove many barriers to access, particularly for those on low incomes, as well as guarantee behavioural intervention accompanies pharmacotherapy use.
Professional training, resources and advice are provided at the state and territory level and vary in each jurisdiction, leading to inconsistencies in service delivery, underperformance and unrealised economies of scale. National standards would ensure health professionals in Australia can provide brief advice to all patients – regardless of medical, psychosocial or cultural needs – and appropriately refer to an accessible and effective multisession behavioural intervention. Systemic changes at the federal level are required to fulfil our obligations under Article 14 of the FCTC.
Evaluation and public reporting of brief intervention strategies and cessation service outcomes are also recommended.
Regulate the design, contents, labelling and disclosure requirements for tobacco products
Regulation of tobacco products can reduce tobacco-related disease and deaths. There are limited regulatory controls of the design and ingredients of cigarettes in Australia.
Flavourings, including menthol, and masking agents are added to tobacco products to increase the palatability of tobacco products by disguising the harsh taste and unpleasant odour of tobacco. Similarly, various cigarette design features are used to increase the palatability of cigarettes, making them more attractive and creating a misleading perception of reduced harm. This is contrary to the intentions of the Tobacco Plain Packaging Act 2011 which aimed to reduce the appeal of tobacco products. The current lack of regulation in this area is of particular concern given that increasing palatability of tobacco products play a role in facilitating smoking initiation among young people. Evaluation of menthol regulations in Ontario has indicated significant reductions of menthol cigarette and total cigarette sales.
Therefore, Cancer Council recommends:
- banning cigarettes containing flavour crush capsules in the filter;
- amending the Tobacco Plain Packaging Act 2011 to standardise the design and appearance of cigarette filters (a single filter type of uniform length, weight and denier of filter fibres and maximum level of plasticiser, prohibit filter capsules and standardise permeability and prohibit perforation of tipping paper);
- objecting to registration of trademarks that include brand names for tobacco products that suggest lower levels of harm, ‘natural’ properties or other features likely to be misleading to consumers;
- introducing legislation that prohibits the manufacturing and importation of tobacco products with variant names that connote social benefits, and use of any additives in any type of tobacco products, including flavourings and menthol.
A significant proportion of Australian adults remain unaware of the serious harms of tobacco use. Research shows that disclosing harmful effects of chemicals present in tobacco packaging increases consumer knowledge on smoking harms. The disclosure of ingredients is largely self-regulated through a voluntary agreement between the Australian cigarette manufacturers and the Commonwealth Department of Health. Implementing testing and measuring of the contents and emissions of tobacco products and their regulation, as well as public disclosure of information on the contents and emissions are needed to increase consumer awareness as well as to fulfil our obligations under Articles 9 and 10 of the Framework Convention of Tobacco Control.
Improving the way in which the Consumers Product (Tobacco) information Standard 2011 and other avenues provide information is needed to improve tobacco users’ understanding of the serious harms of using tobacco products, and to provide appropriate information about available cessation supports.
Regulate the supply of tobacco products
Tobacco products are widely available in Australia through supermarkets, convenience stores, petrol stations and licensed premises. Widespread availability of tobacco products supports smoking by making it easier to access cigarettes and increasing environmental smoking cues. There are currently no limits in any jurisdiction regarding the number of retail outlets where tobacco can be sold. The higher concentration of tobacco retailers in more socioeconomically disadvantaged areas is well documented, and creates greater competition between retailers, leading to lower prices. This has a significant influence on people with lower incomes who are more responsive to price increases. A lack of regulation may also contribute to the normalisation of tobacco use, exacerbating the already high rates of smoking and acceptability among low-income groups, as well as undermine the effectiveness of other tobacco control measures. A key mechanism to regulate the availability of tobacco is a retail licensing system. In Australia, five jurisdictions (ACT, SA, NT, WA and TAS) have a “positive” licensing scheme, which requires tobacco retailers to apply for registration and pay an annual fee prior to retailing tobacco products. Currently, NSW has a “negative” licensing scheme where retailers are only required to notify the government on a one-off basis if they sell tobacco. Victoria and Qld do not have any type of retailer licensing scheme in place. Cancer Council recommends a positive national licensing scheme with a fee to cover the costs of monitoring and enforcement.
Accurate knowledge about the number, type and location of tobacco outlets is essential to monitor tobacco industry activity and to enforce comprehensive marketing restrictions.A retail licensing system can also provide resources required for monitoring compliance, education and training, enforcement and prosecution (e.g. sales to minors). License fees must be set high enough to fully cover the cost of administration of applications, training and education of retailers, and enforcement. Public access to an updated list of licensees and status of any fines or prosecutions must also be made available. It is recommended that annual reporting on sales of tobacco products on a state, regional, electoral and LGA basis should be a requirement of the retail licensing system.
Cancer Council also recommends prohibiting sales of tobacco products in vending machines and banning online sales (or establishing procedures for proof of age verification).
Eliminate all remaining advertising, promotion and sponsorship of tobacco products
Implementation of the Tobacco Plain Packaging Act 2011 and regulations have been effective in eliminating a major remaining form of advertising. The tobacco industry has responded to the introduction of plain packaging by exploiting remaining unregulated elements of product promotion (or those where regulation is limited) including use of evocative variant names and unusual pack sizes. Tobacco promotion also continues through extensive direct and indirect lobbying and public relations programs. Comprehensive bans on advertising, promotion and sponsorship are needed to decrease tobacco use as per Article 13 of the Framework Convention of Tobacco Control (FCTC). Packaging and product design features, payments or other contributions to retailers, vending machines, financial support to venue operators, and corporate social responsibility activities are all included under Article 13 and are areas where Australia is yet to fully meet its obligations.
Some countries have introduced stricter and more effective plain packaging legislation,  and as a result, Australia’s legislation is now below global best practice. Cancer Council recommends updating the Tobacco Plain Packaging Act 2011 and associated regulations to eliminate remaining avenues for advertising and promotion. The Tobacco Advertising Promotion Act 1992 must also be amended to:
- ban payments, incentives and rebates by any tobacco manufacturer, importer or wholesaler to tobacco retailers and proprietors of hospitality venues;
- ban direct advertising/promotional material between industry/manufacturers and retailers;
- prohibit publicity about tobacco industry sponsorship or charitable activities;
- end all public relations and lobbying activities intended to promote tobacco use or purchase tobacco products;
- prohibit tobacco price boards in retail outlets; and
- require regular reporting by any company importing or wholesaling tobacco products in Australia of expenditure and details of any promotion and marketing activities.
Growth in use of social media channels such as Facebook has also created opportunities for the tobacco industry to promote its products due to lack of regulation. Ensuring tobacco advertising bans are inclusive of Internet-based media is also recommended.
Eliminate all exceptions to smoke-free public environments
Comprehensive smoke-free legislation is an effective public health intervention for indoor public places and workplaces to reduce tobacco-related illness. Smoke-free areas have grown in many states and territories in Australia to include outdoor public areas and events, transport waiting areas and public building entrances. However, regulations and definitions differ by jurisdiction, resulting in inconsistencies in regulations across Australia. There are opportunities to further expand smoke-free areas in public places to reduce consumption and uptake of tobacco use among young people. Cancer Council recommends:
- implementing bans on tobacco use in public places (outdoor dining/drinking areas, casinos and gaming areas, public transport waiting areas, health services grounds, prisons, workplaces with outdoor areas where tobacco use is permitted, outdoor sports, recreation and entertainment areas, pedestrian malls, walkways and town squares, and building entrances and ventilation areas);
- implementing/amending regulatory regimes to ensure that smoke infiltration can be addressed in multi-unit housing;
- amending state and territory public housing tenancy requirements to protect public housing tenants from smoke infiltration;
- implementing smoke-free prisons, secure mental health facilities, nursing homes and detention centres; and
- encouraging 100% smoke-free homes and improving education about the dangers of second-hand and third-hand smoke exposure.
Regulate new, novel and/or emerging tobacco products and their promotion
Electronic cigarettes (e-cigarettes) use has risen among smokers in Australia between 2016 and 2019, with daily use rising from 1.5% to 3.2% and at least monthly use increasing from 3.4% to 7.8%. There is strong evidence that e-cigarette use is a precursor to tobacco use in young people and non-smokers. Despite claims that e-cigarettes are 95% less harmful than smoking, there is growing evidence that e-cigarettes can cause health harms, including increased risk of cardiovascular disease, respiratory disease and cancer. The tobacco industry has marketed these products as producing weaker tasting, and less harsh and irritating smoke, which has the intent to attract smokers.
There is insufficient evidence to support the use of e-cigarettes for smoking cessation. The Therapeutic Goods Administration has not approved any e-cigarettes for sale to help people quit smoking. The National Health and Medical Research Council, the Therapeutic Goods Administration and other leading evidence-based agencies do not support e-cigarette use in any form.
Extending tobacco regulation to include e-cigarettes may counter misconceptions and improve the effectiveness of cessation strategies. In June 2020, the Federal Government adopted a strong precautionary and evidence-based approach to the custom regulations of e-cigarettes. Importing e-cigarettes or nicotine liquid refills into Australia without a medical prescription from a general practitioner will become illegal from 1 January 2021.
Cancer Council recommends:
- banning the retail sale of nicotine and non-nicotine electronic cigarettes and other novel products to all, not just under 18-years unless they have received TGA approval;
- banning the use of these products in all smoke-free areas; and
- prohibiting advertising and promotion of these products, consistent with tobacco advertising prohibitions.
Cancer Council and the National Heart Foundation of Australia will continue to monitor research on e-cigarettes and other novel products and provide updated recommendations accordingly.
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