1 - Introduction: the big picture

Table of contents

3 - Progress in Australia on recommended policies and programs

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

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.

Figure 2: Changes in prevalence of daily smoking, Australians aged 14+, 2001–2007 – each Australian state and territory

Source: National Drug Strategy Household Surveys 1998,[36] 2001,[37] 2004[38] and 2007[39] NB. Rates not age-standardised

The 2004 National Tobacco Strategy[7] noted the need for further effort on tobacco regulation, marketing and education, services and treatment for smokers, support for parents and educators, efforts to tackle smoking and disadvantage, and more focused research and education. While there has been some progress in most of these areas since 2005, many of the legislative reforms and programs proposed in the Strategy have not yet been adopted.

Meanwhile the World Health Organization has released a policy package (MPOWER) to guide the 168 countries that are signatories to the Framework Convention on Tobacco Control detailing measures on taxation, health warnings and assistance to smokers to quit.[40] It has also drafted official guidance urging far-ranging restrictions on advertising and promotion.[41] Scheduled for discussion at a meeting of the Conference of Parties in November 2008, these guidelines recommend that parties ban every possible form of advertising and promotion including:

advertising and promotion on tobacco packaging, so that only plain packaging would be allowed
display of products at point of sale
promotion of tobacco companies themselves in order to prevent companies influencing the way in which they and their products are perceived
so-called ‘corporate social responsibility’ donations or contributions by the tobacco industry
other payments by the industry such as incentives to retailers, money to venues to fund the building of smoking areas
internet sales of tobacco products.

In New Zealand, the Republic of Ireland, the UK (led by Scotland) and many states and provinces in the US and Canada, governments have recently introduced (or have announced that they will shortly introduce) measures such as bans on retail displays and restrictions on smoking in cars that are still not yet in place in several Australian jurisdictions.
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The UK, almost all states in the US and several provinces in Canada subsidise NRT for low-income smokers. The UK Government has announced its intention to mandate plain packaging of tobacco products.[42]

After a decade of at least annual and frequently very large increases in taxes, excise duty on tobacco products has not increased even once in Australia over the past six years. In some states, media spending is lower than it has been for several years. Total spending on tobacco control is well below the levels recommended by expert groups.

If smoking rates in Australia were to decline between 2007 and 2019 at the same rate that they declined between 1998 and 2007, prevalence of smoking would³ still be around 14% in 2020.[5] In its blueprint for the nation on Ending the Tobacco Problem, the US Institute of Medicine has proposed a target for the US of 10% adult smoking prevalence by 2025⁴ .[43] This paper sets out how Australia could achieve a target of 9% smoking prevalence by 2020, a full five years earlier. In California, which led the way in the US with a well-funded media campaign commencing in 1988 and a strong push towards smoke-free environments, the prevalence of daily smoking is already less than 9%. It should be feasible for Australia to achieve a reduction in smoking similar to that achieved in California.⁵

A target for 2020 Smoking prevalence of no more than 9% (of Australians 14 years and over, reported smoking daily)⁶ equating to around one million fewer Australians smoking.⁷

¹Including net tangible costs of around $12 billion.
²The contribution of smoking to the incidence and costs of treating most of these diseases in Australia has not been documented.
³Percentage of people who smoke every day or some days each week.
⁴10% of adults 18+ smoking daily or at least some days each week.
⁵The prevalence of daily smoking in California is currently 8.8%. See US Center of Disease Control Behavioural Risk Factor Surveillance system:http://apps.nccd.cdc.gov/brfss/display.asp?cat=TU&yr=2007&qkey=4394&state=CA. To reach prevalence of daily smoking lower than 9% by 2020, smoking rates in Australia would need to reduce over the next 12 years by the same percentage as they have decreased in California over the past 12 years.
⁶9% of Australians 14 plus smoking at least weekly. A target such as this should include a sub-target of an absolute reduction in prevalence among Australians in the most disadvantaged 40% of neighbourhoods at least as great as the reduction in neighbourhoods falling between the 41st and 80th percentile in terms of relative disadvantage. The reduction among Indigenous Australians will need to be considerably greater than this if Close the Gap targets are to be achieved.
⁷From around three million at present to around two million in 2020.

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