Evidence informing policy
This section of the chapter focuses on the evidence informing our policy priorities. It also focuses on interventions for which there is evidence of a positive effect on reducing smoking initiation and prevalence, and increasing quitting.
Mass media antismoking campaigns
Mass media antismoking campaigns (i.e. public education campaigns) have been effective in reducing tobacco use, particularly when coordinated with other tobacco control programs to reinforce messaging and promote awareness. Mass media antismoking campaigns play a role through education, changing attitudes, prompting quit attempts and decreasing smoking prevalence. While mass media antismoking campaigns have a direct impact on smokers by prompting quit attempts and avoidance of smoking, they also have an indirect effect, de-normalising smoking in society.
Television-public education campaigns are the most efficient media channel for reaching and influencing large proportions of the populations. Evaluation of the television-led Quit campaign in South Australia demonstrated that sustained investment, such as repeated cycles of advertising are required for reducing smoking prevalence. During an initial period of substantial investment which resulted in campaign exposure of 700 TARPS/month, smoking prevalence declined from 20.5% to 16.5%. However, when campaigns were abruptly terminated, prevalence rose to 19.4%. Adequate campaign intensity and duration is important, particularly for priority populations. Evidence that campaigns can increase equity if ≥4 tobacco control campaign exposures per person per month are achieved across the population. Lower exposure levels maintain or exacerbate disparities. Evidence-based campaign investment ($30m per year in 2019 dollars) is required to reduce inequalities between low and high socio-economic groups.
Mass media antismoking campaigns are highly cost-effective, as they have high reach into populations.
Mass media antismoking to reduce smoking in groups with high smoking prevalence
The campaign, Don’t make smokes your story has been effective in driving behaviour change and intentions to quit among both Aboriginal and Torres Strait Islander people and non-Indigenous Australians. Evaluation of the campaign found that 7% of Aboriginal and Torres Strait Islander respondents had quit as a result and 26% had reduced the amount they smoked. Furthermore, 20% of Aboriginal and Torres Strait Islander respondents stated they intended to quit smoking as a result of the campaign (28% for non-Indigenous) and 20 % intended to reduce the amount they smoke. Evidence suggests that mainstream advertising is motivating for Aboriginal and Torres Strait Islander smokers, and very few differences exist in the motivational response to emotive mainstream antismoking advertisements with non-Indigenous Australians.
Emotionally evocative TV-led campaigns increase smokers to quit, particularly those from socioeconomically disadvantaged groups. A survey conducted in Victoria of anti-tobacco mass media advertisements demonstrated that greater exposure to fear-evoking messages was associated with higher levels of quit attempts among all socioeconomic groups. Greater exposure to advertisements evoking multiple negative emotions (e.g. fear and sadness) increased quit attempts among those in lower socioeconomic areas.
As well as the Don’t make smokes your story campaign to support cessation among Aboriginal and Torres Strait Islander smokers, evidence shows the addition of population-wide campaigns funded at evidence-based levels would benefit all Australians including Aboriginal and Torres Strait Islander people.
Tax increases have been the single-most cost-effective measure to reduce tobacco use.  With increases in taxes on tobacco products, the size of the resulting price increase leads to a proportional fall in demand. Analysis has found that the 2010 tobacco tax increase in Australia exceeded the set objective of a 6% decrease in tobacco consumption.
The two main reasons smokers in Australia cited for changing their smoking behaviour in 2019 were because smoking was costing too much money (58%) and because it was affecting their health and fitness (45%). The proportion of people nominating cost as a factor increased significantly from 35.8% in 2007 to 58% in 2019 following large increases in excise and customs duty since 2010.
The consistent increases in tobacco excise since 2010 have been paralleled by a consistent increase in quitters, and decreases in the number of cigarettes smoked by regular smokers. The effect was strongest in younger smokers and people on low incomes. Directly following the tax increase in May 2010, one study reported 48% of smokers changed their purchasing behaviour in at least one way. . These changes to tobacco taxes has resulted in increases in the percentages of smokers turning not just to cheaper brands, but also to cheaper forms of tobacco (roll-your own); cartons in preference to packets; and discount outlets.
Tobacco dependence treatment
In 2020, the US Surgeon General reported that mobile phone and internet-based interventions are effective in increasing smoking cessation. Several studies have found that text-messaging programs may support people to quit, particularly short text messages that are interactive or tailored to the individual. There is also evidence to support the effectiveness of internet-based programs for increasing the odds of successful cessation. A meta-analysis indicated that these programs were most effective in the short and long-term when behaviour change techniques were included, such as goals and planning, social support, reward and threat or regulation.
Pharmacotherapies- are effective for increasing smoking abstinence rates. The US Surgeon General in 2020 found that cessation medications are independently effective in increasing smoking cessation, and are more effective than self-help materials or no treatment. Nicotine replacement therapy (NRT), bupropion and varenicline provide therapeutic effects in assisting with smoking cessation. A Cochrane review found that NRTs increase the rate of quitting by 50–60%.
Behavioural and pharmacotherapy interventions combined have been shown to increase the odds of successful quitting by almost 260% (OR 2.58, 95% CI 1.48-2.52).
Design, contents, labelling and disclosure of tobacco products
Flavouring and other additives have been shown to increase the palatability and appeal of tobacco products among non-smokers, particularly youth, causing smoking initiation. Menthol crush-balls are increasing in popularity and appeal to younger smokers. as they mask the harshness of tobacco smoke in comparison with a ‘full-flavour’ cigarette. Data from a 2014 survey of Australian secondary school students revealed that 52% of past-month smokers reported using cigarettes containing menthol flavoured capsules.
Despite sensations of ‘lightness’ when smoked, there is conclusive evidence that ventilated cigarettes do not reduce harm to smokers.Ventilated filters cause smokers to take larger or more frequent puffs, causing smokers to inhale more toxins into parts of the lungs. Evidence shows the harsher and irritating a cigarette, the more harmful it is perceived to be and more motivated the smoker is to quit. Filter ventilation discourages smokers from quitting by increasing palatability and perception of reduced harm. In addition, research strongly suggests that filter ventilation has contributed to the rise in lung cancer among smokers by increasing the toxicant yield of cigarettes.
Health warning labels
Health warning labels have the potential to help reduce smoking prevalence and tobacco consumption. The use of graphic tobacco warning labels is effective in increasing awareness and thoughts about quitting, changing both attitudes and behaviours. A quantitative systematic review of evidence published on the effectiveness of strengthened health warnings on cigarette packs from 20 countries, found that pictorial warnings raised knowledge about harm and Quitline’s, and increased cessation-related behaviour and reductions in smoking behaviour. Individual studies have also shown that warning labels have influenced young people’s attitudes, intentions and smoking behaviour. A UK study reported that warnings had put 90% of youth non-smokers off smoking.
Regulation of product and supply
Greater retail availability of tobacco is associated with higher rates of adult and youth tobacco use, and greater likelihood of smoking relapse among those attempting to quit. Several studies have found that the density of tobacco outlets tends to be higher in areas where there is a higher proportion of residents on lower incomes, increasing exposure to and opportunity to purchase tobacco products.  This proximity to tobacco retailers may promote the transition from experimentation to regular smoking. Evidence shows that seeing a tobacco retail outlet can trigger impulse tobacco purchases and increase smoking frequency among smokers.
Monitoring and enforcing compliance with regulations on the supply of tobacco products are key strategies for reducing smoking initiation. An Australian study found that enforcement of sales to minors legislation resulted in a 73% reduction in attempts by youth to purchase tobacco between 1993 and 2002. Research also found that administrative penalties such as on the spot fines are cost-effective and do not require extensive prosecution.
In Australia, higher merchant compliance in the period from 1997 to 2003 predicted lower levels of daily smoking in adolescents. A 20.8% reduction in daily smoking among Year 10 students during this period was attributed to the improvement in merchant compliance.
Increasing tobacco licensing fees is an effective method for reducing the retail availability of tobacco products.  A South Australian study found that a 15-fold increase in tobacco licensing fees resulted in a 24% decline in the number of tobacco retailers in the subsequent two-years.
Tobacco advertising, promotion and sponsorship
Research shows that tobacco advertising is associated with an increase in overall tobacco consumption.
Numerous reviews have identified tobacco advertising as a key influence on youth to initiate smoking. A 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. In 2013, one-third of young Australians were exposed to online tobacco advertising via social media, particularly Facebook, with viewers mainly aged between 12 and 15 years old and female. A study conducted in the United States found that expressing or receiving pro-smoking messages through online social media had significant associations with smoking attitudes, as well as the initiation of smoking among young university students.
Advertising bans lead to dramatic declines in the awareness of tobacco industry promotional activities. Analysis of tobacco use before and after the introduction of advertising bans in several countries, showed that comprehensive advertising bans reduce smoking initiation by an average of 6% and smoking prevalence by 4%. A partial ban is likely to only reduce prevalence and initiation by 2%.
While comprehensive advertising bans reduce tobacco consumption, incomplete bans have little or no effect because companies transfer expenditure to media where advertising is still allowed. A review of tobacco advertising ban laws in 30 developing countries showed that comprehensive bans resulted in a 23.5% reduction in per capita consumption of tobacco.
Polices that create smoke-free environments have been effective in reducing tobacco-related illness on a number of levels. Evidence shows that smoke-free environments protect individuals from second-hand smoke exposure, denormalise smoking behaviour, help prevent smoking experimentation and uptake among youth, 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 the hospitality industry.
Flow-on effect of smoke-free policies is an increasing number of smoke-free homes, which has an impact on reducing exposure to second-hand smoke, particularly among children. Aboriginal and Torres Strait Islander smokers working in smoke-free workplaces were more likely to have smoke-free homes than those in workplaces where smoking was allowed indoors.
New, novel and/or emerging tobacco products
Research suggests that there are several health risks associated with the use of e-cigarettes and they have the potential to introduce independent or additive health risks. Particulate matter from e-cigarette smoke can aggravate existing illness and increase cardiovascular and respiratory disease risks. Research found that 40% of particles emitted by an e-cigarette can deposit in lungs, with the chemicals contained in these particles potentially irritating airways or worsening pre-existing respiratory conditions, such as asthma and bronchitis. E-cigarettes may also increase the risk of inflammation,, pulmonary toxicity, vascular injury, and infections. Components of e-cigarettes – i.e. acetaldehyde and formaldehyde – are carcinogenic, which may increase risk of cancer. The evidence to support the claims the e-cigarettes are 95% less harmful than conventional cigarettes is limited.
There is growing evidence that e-cigarettes are a gateway to smoking. The Commonwealth Department of Health funded a comprehensive review of the health impacts of e-cigarettes and found that never smokers who used e-cigarettes were 3 times more likely as those who have not used e-cigarettes to try smoking conventional cigarettes and transition to regular tobacco smoking. While several studies have demonstrated that conventional cigarette uptake is more likely among e-cigarette users who would be considered least at risk of smoking, e-cigarettes are becoming particularly common among youth and young adults. A study of non-smoking Australian women aged 20-27 years who use e-cigarettes found that these women are 3.7 times more likely to initiate smoking within 12-months, even after adjusting for sociodemographic and psychological factors. There is evidence that e-cigarettes erode strong social norms against smoking behaviours and risks. E-cigarette users may also develop a nicotine addiction, undermining effective cessation strategies. E-cigarettes with high concentrations of nicotine are associated with the initiation of smoking.
A study in the United States estimated that 3 in 10 heavy smokers were dual users who frequently used e-cigarettes. Dual use is actively promoted by some e-cigarette manufacturers, especially those that also manufacture tobacco products, as a way for smokers to by-pass smoke-free regulations. Other smokers report using both conventional cigarettes and e-cigarettes to reduce the number of conventional cigarettes smoked each day, and/or as an intended pathway for smoking cessation. However, there is insufficient evidence that nicotine-delivering e-cigarettes are a more effective smoking cessation aid than no intervention, non-nicotine e-cigarettes or standard nicotine replacement therapy. Many smokers are unsuccessful in transitioning fully from smoking to vaping, despite initial intentions to quit smoking. There is limited evidence that reduced cigarette consumption reduces mortality among smokers who continue to smoke at a reduced rate.
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