Australia’s report card on smoking-rate reduction is encouraging, but we’ll have to do better to reach the ambitious targets set.
When Australia’s National Tobacco Strategy (NTS) ends in 2018, it will have made real progress in eroding the prevalence of smoking in Australia. Indeed, some experts say by global standards it’s ‘outstanding’. But the fact remains, come the deadline, the NTS will not have met a couple of key targets.
The current 2012–2018 strategy set two main goals. One was to get Australia’s smoking rate below 10 per cent of the general population by 2018.
The December 2015 mid-point review of the strategy, published in 2016, revealed that the smoking rate for those aged 18 and over had dropped to 14.8 per cent in 2014–15 from 16.3 per cent in 2011–12. Subsequently, the 2016 National Drug Strategy Household Survey found that the rate of ‘daily smoking’ among people aged 14 or more was 12.2 per cent. Progress was encouraging, but the results were falling frustratingly short of the target set.
The other headline goal was to halve the prevalence of smoking among our Aboriginal and Torres Strait Islander population, from the alarming 2008 level of 47.7 per cent.
According to the 2014–15 National Aboriginal and Torres Strait Islander Social Survey, the proportion of Indigenous people aged 15 and over who were daily smokers was down to 39 per cent.
“Australia has made a lot of progress, but we’re probably not going to achieve the 10 per cent target for the national smoking rate,” says Maya Rivis, Principal Program Officer, Alcohol and Tobacco at VicHealth.
“And while the prevalence of smoking in the Aboriginal and Torres Strait Islander population has reduced, it has nowhere near halved. So while you could say that both goals won’t be met by 2018, it’s arguably better to be more ambitious with your targets than less,” notes Rivis.
Indicators of progress
Outside of those missed headline targets, Rivis says that efforts to change Australian smoking behaviours are progressing well across most of the performance indicators set by the NTS. Indeed, the 2015 mid-term review showed improvements in 11 of the 14 indicators, and there were no indicators with a change in an adverse direction.
Rivis adds that Australia is experiencing strong success in reducing the take-up of smoking by young people. According to the 2016 National Drug Strategy Household Survey, the proportion of teenagers who have never smoked more than 100 cigarettes rose from 95 per cent in 2013, to 98 per cent in 2016.
Falls were also recorded in the number of secondary students who smoked regularly, with a decline of almost a quarter.
The survey also showed that the proportion of adult ‘ever-smokers’ (people who had smoked more than 100 cigarettes in their lives) who had now quit smoking rose from 47 per cent in 2013 to 52 per cent in 2016.
Smoking and social disadvantage
“Most of the indicators are tracking well, but there are areas where we face difficulties,” says Rivis. “The population groups where we’re finding it most difficult to change behaviour are those experiencing disadvantage and lower socio-economic demographic groups.
“The gap between the smoking rates among people who are well-off socio-economically and the population groups that are not well-off is widening, and we need to see that gap narrowing."
Rivis says the relationship between smoking and social disadvantage is complex and entrenched. “For every indicator of disadvantage a person has, their likelihood of smoking increases. Essentially, if you are low-paid, or long-term unemployed, if you have a poor education, a mental illness, or a drug and alcohol disorder, you’re much more likely to smoke than the average person, and you’re far less likely to quit. You end up smoking for longer and the harms are greater.”
Moreover, this becomes self-reinforcing. “If a stressful event happens in your life – which happens more often if you are disadvantaged – you end up relapsing into smoking.
“And not only does experiencing social disadvantage increase the risk of being a regular smoker: smoking can compound that disadvantage by reducing the funds available for essentials such as food, clothing and housing,” Rivis says.
Building on existing successes
The next national tobacco strategy is likely to build upon the main approaches of the current strategy, Rivis believes, with further investment in population-wide tobacco control interventions in particular, such as increasing the price of tobacco and continuing mass-media campaigns.
As well, she expects an emphasis on strengthened social policies to reduce health inequities, and heightened efforts to identify and invest in targeted approaches to influence smoking’s stubborn prevalence among disadvantaged groups.
“There needs to be more of a focus on getting people to quit. We’re really good at preventing uptake – fewer kids smoke now than ever before. But getting people who smoke to quit is a lot harder. I suggest there will be more of an emphasis on that,” adds Rivis.
Dr Sarah White, director of Quit Victoria, says the strategy has a "really good scorecard’, and there are standout actions that will need to be rolled into the next iteration. “We have seen what works,” she adds.
In particular, says White, the emphasis on strong public education campaigns should be bolstered. “We know (these campaigns) have a disproportionately good effect on people with socioeconomic disadvantage; and also preventing kids from taking up smoking, and we’d like to see more money put into targeted public education programs.
“Across Australia we’ve seen those public education campaigns slide to generally below evidence-based levels of effectiveness: we know what level of exposure people need to have, how many times people need to be exposed to those big campaigns, to have an effect; and we are not yet at those levels of exposure that have been proven to motivate and support people who smoke, to quit,” she says.
White is also pleased with the ongoing effort to ‘denormalise’ smoking in the community. “Young people don’t see smoking as something to aspire to, they don’t see people smoking when they go out, they don’t see it as something cool on ads on TV. That denormalisation has certainly helped. Denormalisation is boosted by smoke-free legislation, the anti-smoking messages, and the pro-health messages from Quit, VicHealth, the Cancer Council and Heart Foundations. They’re really important as well,” she says.
Rivis also believes there needs to be more of a focus on getting people to quit. “We’re really good at tobacco control, and in limiting the uptake – fewer kids smoke now than ever before – we’ve done a great job preventing people from smoking, but getting them to quit is a lot harder. I suggest there will be more of an emphasis on that,” adds Rivis.
Professor Mike Daube, of the Faculty of Health Sciences at Curtin University, says progress on tobacco control is always slow. “If you’re looking for miracle change, overnight, you’ve come to the wrong public policy area,” he says.
“By any standards, Australia’s progress has been quite extraordinary over the last 30 or 40 years, outstanding by global standards, particularly given the immense opposition that we’re facing, and the incredibly limited resources that have been devoted to it.
“But it is true we’ve done well in some areas, and in the last three to five years, not so well in others,” he says. “We must remember that national strategies are wonderful, over-arching statements, but they’re not something against which governments can see, on a day-to-day basis, how they’re performing.”
The United Kingdom’s most recent tobacco control plan, Towards a smoke-free generation, was launched in July, with a target of cutting the country’s smoking rate from the current 15.5 per cent – an all-time low – to 12 per cent or less by 2022, and slashing the smoking rate among the young from 8 per cent of 15-year-olds to just 3 per cent. The plan notes that e-cigarettes are ‘significantly less harmful to health’ than traditional tobacco products and explicitly supports the adoption of these and other ‘less harmful nicotine products’ as a means of stopping smoking.
Canada’s current national tobacco control strategy is set to expire in March 2018. The Canadian government has committed to reducing national tobacco use from the current level of about 13 per cent to less than 5 per cent, saying it is prepared to take an aggressive approach to meet its ambitious target.
Policies being considered include raising the minimum age for the purchase of tobacco products to 21, developing regulations to reduce the addictiveness of tobacco products, and banning smoking on campuses, in parks and in multi-unit apartment buildings.
Canada is also looking at ways to help people quit or reduce their use of tobacco products, possibly through a shift to alternative products such as e-cigarettes.
A combination of approaches
Daube says Australia understands that there is ‘no silver bullet’ in tobacco control. “There is no killer app that’s going to bring us down to 5 per cent, which, given that tobacco is a legal product – and a highly addictive one – is regarded as society being effectively smoke-free.
“It’s always a combination of approaches, a comprehensive strategy, with bits feeding into and influencing other areas.
“Excise is obviously one of the main planks of the strategy – it ramps up the price of the product, and excise is pretty good for the government, because it gets revenue from it. So we can have continuing quite substantial tax increases.
“Second, we can’t let up on publicising the overwhelming evidence about the harms of smoking – we’ve got to keep reminding ourselves of the magnitude of the problem.
“Third, we need continuing mass-media campaigns over time.
“Fourth, we have smoke-free measures which we can extend further.
“Fifth, we have regulation, and curbing tobacco promotion: plain packaging has been a key part of curbing tobacco promotion,” says Daube.
All of these are the ‘policy termites’ that are “slowly eating out the foundations of smoking,” says Simon Chapman, Emeritus Professor in Public Health at the University of Sydney.
“These factors do not act in isolation, but like a constant and unstoppable termite colony, work in synergy to erode the appeal of smoking,” says Chapman.
And they’re working, he says. “The male lung cancer incidence rates of today were last seen in the early 1960s, and women’s seem likely to never reach even half the peak seen at the height of the male epidemic. We need to stay the course and make smoking history.”
Excising the problem
In recent years, tobacco excise has been one of the government’s main weapons against smoking. In 2010 there was a one-off increase in excise of 25 per cent, and since 2013 there have been annual excise increases of 12.5 per cent with the most recent in September.
These annual excise increases are set to continue through to 2020.
Many smokers have switched to cheaper roll-your-own tobacco and, coinciding with the September excise, a change was made to the way roll-your-own tobacco is taxed, aligning it with the tax treatment of factory-made cigarettes.
Although excise increases are one of the main weapons against smoking, they are a ‘blunt weapon,’ says Maya Rivis at VicHealth. “Taxation is very effective – but it has its limitations.”
According to Rivis, excise rises fall disproportionately on economically disadvantaged smokers. She expects to see the tobacco industry move, in a perverse way, to help its addicted customers by adjusting its margins.
“The tobacco industry is a master at manipulating its prices,” she says. “It will charge more for the premium end, but discount the cheaper end, to keep those who are struggling to afford the more expensive cigarettes the ability to be able to afford smoking,”she says.
Dr Sarah White, director of Quit Victoria, believes that influencing the price of cigarettes through excise is a very effective measure, even if increased excise is seen, in some quarters, as a regressive tax. “We know that money that goes towards smoking is money that doesn’t go to families, it doesn’t go to food, it doesn’t go to education. That’s an incredibly big problem,” says White. “It’s always a worry; does the tax become regressive for some groups? The counter-argument is that it is socially regressive not to use every measure we can help people who are struggling to get off cigarettes.”
As people continue to smoke, not only does their health decrease, but also their employment opportunities suffer. “We sometimes forget that economics is not just about money, it’s also about productivity and the ability to earn money. People who continue to smoke, and whose health is damaged by smoking, lose some of their ability to earn money,” says White.
e-cigarettes under scrutiny
An alternative to cigarettes that has arisen in recent years is the e-cigarette, a personal vaporiser that heats liquid nicotine to give the smoker a nicotine dose through vapour, rather than smoke.
According to the National Drug Strategy Household Survey 2016 , nearly one-third of smokers have tried an e-cigarette. Despite the large numbers of smokers trying e-cigarettes, there is ongoing debate in the research community as to the levels of harm posed by e-cigarettes, and whether they are a useful aid in helping people to quit smoking.
Currently, e-cigarette hardware is legally available in Australia, but the nicotine contents are not, without a doctor’s prescription.
The House of Representatives Standing Committee on Health, Aged Care and Sport is presently examining the use and marketing of e-cigarettes and personal vaporisers in Australia – and the implications of the growing body of research on the health impacts of e-cigarettes. This work is aimed at making recommendations on an appropriate framework for the regulation of e-cigarettes in Australia.
The National Tobacco Strategy (2012–18) measures its performance using 14 indicators. The figures below demonstrate the progress made at the time of the mid-term review in 2015.
1. Fewer young people smoking regularly: from 6.7 per cent in 2011 to 5.1 per cent in 2014.
2. Fewer young people making the transition to established patterns of smoking: from 3.5 per cent in 2011 to 2.7 per cent in 2014 for the 12–17 age group; from 29.4 per cent in 2011 to 23.2 per cent in 2014 for the 18–24 age group.
3. Fewer adults smoking regularly: from 18.9 per cent in 2007–08 to 14.5 per cent in 2014–15.
4. More smokers attempting to quit: from 44.8 per cent in 2010 to 46.7 per cent in 2013.
5. Fewer women smoking while pregnant: from 12.9 per cent in 2011 to 11.3 per cent in 2013.
6. Fewer children exposed to second-hand smoke at home: from 6.1 per cent in 2010 to 3.7 per cent in 2013.
7. Fewer adults exposed to second-hand smoke at home: from 4 per cent in 2010 to 2.4 per cent in 2013.
8i. Fewer adults smoking regularly among Aboriginal and Torres Strait Islander people: from 47.7 per cent in 208 to 44.4 per cent in 2012–13.
8ii. Fewer adults smoking regularly among people of low socio-economic status: from 30.6 per cent in 2007–08 to 20.6 per cent in 2014–15.
9. Young people delaying the onset of tobacco smoking: from 15.4 years in 2010 to 15.9 years in 2013.
10. Fewer people trying cigarettes (broken into secondary school students, and adults): from 23.3 per cent in 2011 to 19.1 per cent in 2014 for the 12–17 age group; from 62.5 per cent in 2011 to 57 per cent in 2013 for those aged 18 and older.
11. Adult ever-smokers are quitting at a younger age: from 35.3 in 2010 to 35.4 in 2013.
12. More adult ever-smokers no longer smoking: from 47.4 per cent in 2011 to 51.8 per cent in 2013.
13. Fewer young people smoking: from 8.9 per cent in 2011 to 7.5 per cent in 2014.
14. Current adult smokers smoking occasionally (weekly or less than weekly): from 9 per cent in 2007–08 to 9.6 per cent in 2014–15.