Effective interventions

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Effective interventions


Australia has a strong record of tobacco control and has implemented a number of successful interventions for reducing tobacco use. The success of Australian tobacco control policy is reflected in the declining rates of smoking[1]. Despite this, more than one in six Australian adults smoke daily, accounting for 2.8 million people in 2011-2012[2].

This section of the chapter focuses on interventions for which there is evidence of a positive effect on smoking initiation, quitting and prevalence, and for which there remain opportunities for improving tobacco control in Australia.

Overarching frameworks

Effectively reducing the burden of smoking-related cancer in Australia enquires a coordinated, multi-strategy approach with intervention and funding from all levels and sectors of government, as well as non-government, community and health organisations[3].

A number of policy frameworks exist in Australia to address this, including the Council of Australian Government Agreements for Healthcare[4], Preventive Health[5] and Closing the Gap in Indigenous Health Outcomes[6]. These agreements are designed to facilitate Federal and State and Territory Government cooperation.

The National Tobacco Strategy 2012-2018 is a policy framework designed to provide a platform for government at all levels to work with non-government, community and health organisations[7].

See the Policy context section of this chapter for more on the current policy environment in Australia.

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Taxation

Tax increases have been one of the most effective tobacco control strategies in Australia and globally[8][9]. With increases in taxes on tobacco products, the size of the resulting price increase leads to a proportional fall in demand[10].

Tobacco taxation, including federal excise, customs duty and state franchise fees has been a central tobacco control strategy in Australia. In Australia, excise, customs duty and GST make up around 60% of the final price of leading brands of cigarettes[8][11]. The Australian Government has regularly indexed tobacco excise by the Consumer Price Index. However, from 2014 onwards, tobacco excise is to be indexed on the basis of changes in Average Weekly Earnings. In April 2010, a 25% tax increase on tobacco products was introduced. In 2013, the Government announced it would introduce staged 12.5% increases in tobacco excise over four years from 2013-2016, in addition to the increases that will occur under indexation arrangements.The first two 12.5% increases commenced on 1 December 2013 and 1 September 2014, and the remaining 12.5% increases will occur on 1 September 2015 and 1 September 2016, respectively.

Analysis by Federal Treasury found that the 2010 tobacco tax increase in Australia exceeded the set objective of a 6% decrease in tobacco consumption, with a decline of 11% two years after implementation. There was insufficient data to determine whether the increase met the objective of decreasing the number of smokers by 2-3%[12]. The analysis concluded that the excise increase supported other policy, price and taxation measures aimed at reducing the harms of tobacco consumption in Australia[12].

The two main reasons smokers in Australia cited for changing their smoking behaviour in 2010 were because smoking was affecting their health (44.3%) and because it was costing too much money (44.1%). The proportion of people nominating cost as a factor increased significantly from 35.8% in 2007 to 44.1% in 2010 when the tax increase was introduced[1].

The 2010 tax increase saw increased numbers of people attempting to quit, and decreases in the number of cigarettes smoked by regular smokers[13][14]. The effect was strongest in younger smokers and people in the lowest socioeconomic tier[13][14]. Directly following the tax increase (May 2010), one study reported 22% of the study sample quit smoking, compared with 12% at the same time in the previous year and 13% in the previous month[15]. This increased number of people quitting was evident for a short time, however this was not sustained further than three months following the tax increase[15].

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Mass media campaigns

Mass media campaigns, including social marketing, can have a significant impact on reducing tobacco use[16][17]. Mass media campaigns play a role through education, changing attitudes, prompting quit attempts and decreasing smoking prevalence[16]. They have a direct impact smokers by prompting quit attempts and avoidance of smoking, and also have an indirect effect by de-normalising smoking in society[17].

Television campaigns remain the primary mass media channel for reaching and influencing adult smokers[16]. Developing sustained mass media campaigns, such as repeated cycles of advertising, are the most effective medium for reducing the burden of tobacco-related cancer[18]. There is evidence that while mass media campaigns are effective at increasing quit attempts, the impact does not last beyond a few months of the campaign ending[18]. Adequate campaign intensity is especially important for vulnerable population subgroups[17].

Mass media campaigns are highly cost-effective, as they have high reach into populations[17]. The savings from averted health care costs associated with tobacco control mass media campaigns exceed campaign costs[17].

Mass media campaigns are a particularly effective component of comprehensive tobacco control strategies[19]. Their effectiveness is maximised when coordinated with other tobacco control programs to reinforce the messaging and promote awareness. Mass media campaigns and pictorial health warnings running concurrently may have a complementary effect on increasing awareness of the harms of smoking and motivation to quit[19].

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Eliminating tobacco advertising, promotion and sponsorship

While many avenues of tobacco advertising, promotion and sponsorship have been restricted, there still remain avenues by which tobacco companies seek to promote their products. The rise of new media and lack of relevant regulations have created an environment in which tobacco control is hampered by the tobacco industry denormalising public health strategies and policies[20]. Eliminating remaining forms of promotion such as internet advertising, price specials, public relations activities, incentive programs and exemptions to point-of-sale display restrictions is an obligation under the World Health Organization Framework Convention on Tobacco Control[21].

The role of tobacco advertising remains important particularly in smoking initiation. A recent meta-analysis demonstrated that non-smoking adolescents who were more aware of tobacco advertising were more likely to experiment with cigarettes and to become smokers[22].

Enforcing plain packaging laws, which commenced in Australia on 1 December 2012, is an important strategy to reduce young people's exposure to tobacco promotion. In an environment where the majority of advertising streams for tobacco products are blocked, product packaging is an important marketing tool for tobacco companies[23][24].

Early indications suggest that plain packaging of tobacco products is associated with lower smoking appeal and higher urgency to quit among adult smokers[25]. Smokers using plain packs are 81% more likely to have thought about quitting at least once a day during the previous week, and to rate quitting as a higher priority compared with those using branded packs[25]. Smokers using plain packs were 66% more likely to think their cigarettes were poorer quality than a year ago and 70% more likely to say they found them less satisfying[25].

See the Quit Victoria and Cancer Council Victoria Plain packaging review of evidence for more information.

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Smoke-free environments

Polices that create smoke-free environments are effective at reducing tobacco-related illness on a number of levels. Smoke-free environments protect individuals from second-hand smoke exposure[26], denormalise smoking behaviour[27], help prevent smoking experimentation and uptake among youth[27][28][29], and provide an environment that helps promote quit attempts.

The creation of smoke-free environments has had a net benefit to businesses, with no adverse effect on sales in hospitality industry[29].

Flow-on effect of smoke-free policies is an increasing number of smoke free homes, which has an important impact on reducing exposure to second-hand smoke, particularly among children[30][29]. See the section on Links between smoking and cancer for more information.

Commonwealth regulations ban smoking on domestic and Australian-operated international flights. However, the majority of regulation of smoke-free areas is implemented at a state level. Differences in regulations and definitions result in inconsistencies in regulations across Australia. See Table 1 for a brief overview of state regulations.


Table 1. Overview of state level smoke-free environment regulations

State/territory Enclosed public places* Outdoor eating/ drinking areas In cars (children present) Outdoor public venues
ACT Banned Banned (exception for designated areas) Banned
NSW Banned Banned Dependent on local council jurisdiction
NT Banned Banned Banned Banned
Qld Banned Banned (exception for designated areas) Banned Banned in stadiums, children’s playgrounds, patrolled beaches. Additions dependent on local council jurisdiction
SA Banned Banned Banned in children’s playgrounds, public transport stations
Tas Banned Banned Banned Banned in sporting and cultural venues, beaches and children’s playgrounds
Vic Banned Banned Banned in public transport stations. Additions dependent on local council jurisdiction
WA Banned Banned Banned Banned at beaches and children’s playgrounds

* Includes public transport

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Targeting disadvantaged and high-risk groups

Smoking rates in highly-disadvantaged groups are significantly higher. These communities bear a disproportionate burden of tobacco-related illness. See the Impact section of this chapter for more information.

Tobacco control measures effectively used in the general population may or may not be effective in specific high-risk populations. A recent meta-analysis of cessation support programs in highly disadvantaged groups cited the lack of high-quality evidence in these populations, particularly among the homeless, Indigenous Australians and prisoners[31]. Similarly, a review of mass-media campaigns targeting disadvantaged populations reported a lack of high quality evidence, particularly for highly disadvantaged communities[32]. Evaluation of the effectiveness of population-based tobacco control strategies in these specific populations, and appropriate tailoring where appropriate, is necessary to effectively target tobacco-related disparities.

Alliances between expert organisations in tobacco control and social services, mental health services, correctional facilities and government are key to assisting disadvantaged groups. These partnerships are important for the development of capacity in community organisations and for the implementation of targeted strategies for specific populations to complement mainstream programs. Current examples include the Cancer Council NSW Tackling Tobacco program which partners community organisations to promote quit attempts and the Break Free Alliance in the US who unite health departments with community organisations and public health advocates.

See the Cancer Council Australia position statement on Tobacco related disparities for more information.

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Product and supply regulation

Tighter regulation of tobacco products can increase understanding of the health impacts, counter misconceptions of ‘healthier’ options, decrease take-up and increase quit attempts.

The introduction of pictorial warnings in Australia resulted in an increase in people noticing and reading health warnings, considering the health risks, smoking fewer cigarettes, and quitting[30]. The pictorial warnings also stimulated stronger cognitive responses and more reports of reduced tobacco consumption than text-only health warnings in the UK[30].

Monitoring and enforcing compliance with regulations on the supply of tobacco products are key strategies for targetting smoking initiation. In Australia, higher merchant compliance from 1997–2003 predicted lower levels of daily smoking in adolescents[33]. A 20.8% reduction in the odds of smoking among 10th graders during this period was attributed to the improvement in merchant compliance[33].

Disclosure

All government jurisdictions in Australia have endorsed the National Tobacco Strategy 2012-18, which includes a commitment to "consider further regulation of the contents, product disclosure and supply of tobacco products and alternative nicotine delivery systems"[34].

The Commonwealth Department of Health and Ageing is leading two projects to assess the feasibility of improved tobacco product regulation in Australia. One is focused on the scientific, technical and practical feasibility of regulating the disclosure of tobacco product ingredients and emissions data in Australia. Public consultations are currently underway. There is also a literature review and research into the relationship between tobacco product ingredients, palatability and smoking behaviour.

Since September 2010, all cigarettes in Australia have been required to meet a reduced fire propensity standard.

See Cancer Council Australia position statements on Dangers of 'reduced-harm' cigarettes for more information.

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Cessation services

Close to three in 10 (29%) smokers in Australia tried unsuccessfully to quit smoking in 2010[1]. Almost 40% reduced the amount they smoked in a day[1].

Behavioural interventions such as individual, group and telephone counselling may be effective at improving smoking cessation, as measured at six and twelve months after quitting[35][36]. Pharmacotherapy-based interventions such as nicotine replacement therapy can improve smoking quit rates by 50–70%[37] and a combination of behavioural and pharmacotherapy interventions can increase smoking cessation success even further[38].

Given the effectiveness of cessation services, improving access to such services is an important strategy to reduce the burden of tobacco-related illness. This is particularly important for reducing the tobacco burden in disadvantaged groups. Understanding the barriers to uptake of cessation services among disadvantaged groups is an important step in increasing their access and use. See Targeting disadvantaged and high-risk groups for more information.

Further development of existing services is important for integration of cessation support into routine care, tailoring of services for specific high-risk groups, implementing best-practice and improving awareness and uptake.

See the Cancer Council Australia position statement on Stopping smoking for more information.

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Research and monitoring

Ongoing research and monitoring of current interventions is important to assess and improve intervention effectiveness, and to enable the dissemination of evidence within the international tobacco control community.

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References

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Overview   Impact   Link   Policy context   Effective interventions   Policy priorities   Position statements