AUSTRALIA was a world leader in tobacco control over recent decades and smoking rates fell steadily. Mike Daube and colleagues should be rightly proud of their efforts at the helm of tobacco control during this time.
However, despite the highest cigarette prices in the world, plain packaging and comprehensive tobacco control policies, Australian smoking rates have stalled for the first time in decades, while declines accelerated in some other countries such as the US.
There was no significant fall in Australian smoking rates from 2013 to 2016, according to the 3-yearly National Drug Strategy Household Surveys. Adult smoking rates increased in New South Wales from 13.5% to 15.1% between 2015 and 2016, and cigarette consumption rose in 2017 for the first time in a decade according to the National Accounts.
We need to have a polite and respectful debate about Australia’s tobacco policies and consider possible new strategies to help achieve the national smoking rate target.
Stop tobacco tax rises
Increasing tobacco taxes is a proven strategy for reducing smoking rates but may not work as well at the upper end of the price range. A 20-pack of Marlboro costs an eye-watering $26 in Australia but only $9.30 in the US and $2 in Indonesia. At these levels, tobacco prices in Australia may be doing more harm than good in Australia.
It is very likely that tax rises have a decreasing net impact at these very high levels (the law of diminishing returns). Many addicted smokers continue to smoke regardless of the price.
Very high tobacco taxes are also a social justice issue. They exploit the most disadvantaged members of the community, such as Indigenous people, low socio-economic status groups and people with mental illness who have lower quit rates. For those unable to quit, high taxes are regressive, punitive and increase financial hardship and health inequalities.
Another unintended consequence of high prices has been the exponential growth in the illicit tobacco industry. Illicit tobacco from smuggling and illicit tobacco crops make up 15% to 28% of the total tobacco market and funds organised crime and terrorism.
Encourage tobacco harm reduction
Tobacco harm reduction refers to substituting lower risk products such as e-cigarettes for combustible tobacco products for smokers who cannot or will not quit. Harm reduction, along with demand reduction and supply reduction are the three pillars of Australia’s National Drug Strategy, but smokers are strongly discouraged from using these products.
We cannot know in advance with absolute certainty the future impact of e-cigarettes, so we have to go with the best available evidence, which indicates that:
- e-cigarettes are far safer than smoking;
- where e-cigarettes are widely available, adolescents are giving up smoking at an unprecedented rate;
- e-cigarettes are now the most popular quitting aid in the UK, the US and Europe;
- e-cigarettes appear to be increasing smoking cessation in population studies, especially among daily users;
- millions of ex-smokers report quitting with e-cigarettes overseas;
- even if e-cigarettes cause some never-smoking adolescents to try smoking, a moderate rate of increased smoking cessation by adults vaping produces a net public health benefit.
It would be a mistake to delay these products for another 20–30 years until we have total scientific certainty. Too many lives are at stake. The known harms from smoking far outweigh any uncertainties around tobacco harm reduction options such as vaping. Continuing to smoke carries a two in three risk of being killed by smoking.
The Big Tobacco myth
Tobacco companies have a long history of dishonest, manipulative and illegal behaviour and it is right to be suspicious of their motives. However, it is wrong to automatically assume that everything they do is harmful to public health.
Vaping is a grassroots, consumer-led movement by addicted smokers wishing to reduce their harm from combustible tobacco, at no expense to the public purse. Big Tobacco has been forced to enter the reduced-risk products market with e-cigarettes and heat-not-burn products to avoid being made irrelevant by a new and disruptive technology.
Big Tobacco is only a minority player and owns less than 15% of the e-cigarette market in the US (Wells Fargo, April 2018) and UK, and sells no e-cigarettes in Australia, Canada or New Zealand.
Some tobacco control activists are consumed by a commitment to destroy the tobacco industry. However, the focus should be on reducing smoking-related death and disease, not on destroying the tobacco companies. It is better for public health if tobacco companies switch to making less harmful alternatives rather than lethal cigarettes.
Help smokers to quit
The most effective way to reduce smoking is to combine strategies to motivate smokers to quit along with support to help them succeed. Mass media campaigns are effective at stimulating quit attempts and should be reintroduced but have once again been neglected in the recent Budget. However, the majority of attempts triggered by these campaigns are unsuccessful. In particular, the quit rate from unaided quitting is less than one in 20.
Significant and sustained funding should be provided to help smokers quit, especially those from disadvantaged groups where smoking rates are very high. Of the current $12.5 billion collected annually in tobacco excise and GST, very little is allocated to cessation support, although it is one of the most cost-effective medical interventions. Some of the tobacco excise should be hypothecated to help the smokers who pay it.
Substantial resources should be allocated to training health professionals, funding smoking cessation clinics, reimbursing smoking cessation services and subsidising a wide range of nicotine replacement products for combination therapy (nicotine patch plus gum, spray, lozenge or inhalator).
More carrots and less stick
A more compassionate and effective approach will kick-start the decline in smoking rates. Instead of increasing financial penalties for addicted smokers, we need to provide more professional support to help them quit. For those who still cannot or will not quit, safer alternatives such as vaping should be made available. The human cost of the continued high smoking rates is too great to be complacent.
Colin Mendelsohn is an associate professor at the University of New South Wales’ School of Public Health and Community Medicine. He is chairman of the Australian Tobacco Harm Reduction Association. He has received payments for teaching, consulting and conference expenses from Pfizer Australia, GlaxoSmithKline, Johnson and Johnson Pacific, and Perrigo Australia.
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