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Nature of the Problem: Tobacco continues to be Australia’s leading preventable cause of illness and death, which takes 20,000 lives per year (Gordon & Preston, 2023). Tobacco smoking is associated with many life threatening diseases such as lung cancer, cardiovascular diseases and chronic obstructive pulmonary disease (COPD) which exert a great burden on the nation’s health care system. Apart from affecting the health of the people, smoking has a large economic implication since it costs billions of dollars in healthcare and lost productivity. Although, the rates of smoking have come down significantly due to the measures like plain packaging, higher taxes, and awareness campaigns, tobacco use remains a major issue for millions of Australians. Indigenous Australians, low-income earners, and people with mental health problems continue to be at a higher risk of smoking, and therefore, require continued and more focused efforts in order to reduce the prevalence of smoking and its negative impacts on social and economic well-being.
Extent of the Problem: The daily smoking rate in Australia has also come down and was last recorded at 11.6% of the adult population, down from 23.8% in 1995 due to the country’s national tobacco control measures like high taxes, plain packaging and mass media campaigns (Davey, 2021). But this general trend has been able to hide the fact that there are still inequalities that exist among some groups of the population. For example, Indigenous Australians still have shockingly high smoking prevalence, with more than 40% of Indigenous adults smoking daily compared to the national rate (Davey, 2021). Furthermore, smoking rates are higher among the rural and remote population, the low-income earners and persons with mental illness. Such groups are usually more vulnerable to the products since the tobacco industry markets them directly. This exposure further widens the gap in the health disparities because smoking-related diseases become more prevalent among disadvantaged individuals, thus continuing the cycle of poor health.
Impact of the Problem: Tobacco use is not only a problem affecting individual smokers, but also a huge social cost to the Australian society and its healthcare system. Diseases associated with smoking are costly diseases and their treatments demand a lot of care and time for instance lung cancer, heart diseases, and COPD. A study done in 2015 estimated that tobacco use cost Australia’s economy about $137 billion in health care, productivity in terms of time off work and early mortality (Roche et al., 2021). The social costs of tobacco are equally as high and take their toll on the productivity of work through increased absenteeism and early retirement, which puts more strain on the labour force. To the family members and the society at large, tobacco use is destructive to the smoker as well as to the society as it causes emotional and financial losses in the event of sickness. Such costs are borne more heavily by those at the lower end of the socio-economic scale and thereby perpetuate poor health and poverty.
Smoking in Australia is on the decline; however, some of the most vulnerable groups of the population remain affected. Smoking is another major health risk where Indigenous Australians are affected worst; 40% of the Indigenous adults are daily smokers compared to the 11.6% of the general population (Davey, 2021). Such differences are due to numerous factors, including past wrongs, like the provision of tobacco as a rations during colonization, and current societal disparities. Other vulnerable groups include Indigenous peoples, rural and remote residents, and smokers, whose prevalence is much higher than in large cities. Many of these populations are not only denied adequate healthcare, but also smoking cessation programs, and information on the risks of smoking.
The National Drug Strategy Household Survey (2021) revealed that smoking continues to be more common among the disadvantaged population, persons with mental health disorders, and those in rural settings (Buchanan et al., 2021). Cigarettes are employed in the management of stress and other mental health disorders, which makes it hard for the affected individuals to quit smoking without assistance.
These groups are especially vulnerable to targeted marketing by the tobacco industry which also exposes them to aggressive campaigns and discounted tobacco products. Therefore, not only are the disadvantaged groups more likely to smoke but they are also more likely to suffer from the diseases associated with smoking leading to increased health disparities across the country.
This supports that there is need for special tobacco control measures that will address these disparities. Tobacco use also causes second-hand smoke, which leads to respiratory diseases and other illnesses in non-smokers, especially the young and the aged (Braun et al., 2020). In addition, tobacco affects environment since it causes litter and pollution through discarded cigarettes which are seen in the urban areas.
Social Context: The use of tobacco has a long history in Australia and especially among the vulnerable groups. Smoking became part of Indigenous Australians’ lives when during the colonial period they were paid in tobacco rations (Waa et al., 2020). This has been further compounded by advertising strategies employed by the tobacco industry that has seen high rates of smoking among Indigenous populations in the contemporary world. Smoking is still socially acceptable in many low-income and rural areas, which are underserved when it comes to cessation services and where smoking is a way to deal with stress and other mental health problems.
Tobacco addiction is a major problem in mental health patients. The relationship between mental illness and smoking is quite clear, with smokers with mental health disorders being twice as likely as the general population to smoke (Hindocha et al., 2021). This is usually attributed to the use of tobacco in the treatment of some ailments, but it also worsens other illnesses. Culturally, smoking is becoming less acceptable, and more associated with deprivation, with higher income groups quitting at a faster rate than lower income groups. Smoking is thus becoming more and more confined to the socially and health disadvantaged populations thereby perpetuating social and health disparities.
Political Context: Australia has been at the forefront of implementing tobacco control policies for many years and was the first country to implement plain packaging, ban on comprehensive advertising, and high tobacco excise taxes (Moodie et al., 2022). These policies have helped in the decrease of smoking prevalence in the country as will be discussed below. Such measures as plain packaging launched in 2012 are good examples of a breakthrough that was followed by other countries. Nonetheless, the tobacco industry remains a powerful force, especially in legal actions against new measures and in lobbying. The industry has in the past employed strategies such as ‘regulatory chill’ where legal cases are brought against governments to prevent them from passing even more stringent regulations.
The National Tobacco Strategy (2023-2030) is based on the principle of Australia’s sustained tobacco control efforts that focus on 11 strategic directions including smoking prevalence reduction, social and economic burden of tobacco, and equity (Mills et al., 2022). The strategy focuses on the elimination of tobacco use in disadvantaged groups, such as Indigenous Australians, people with mental illness, and those living in rural and remote areas. It also underlines the importance of sustaining public awareness campaigns, improving legislation on tobacco marketing and distribution and increasing the level of investment in smoking cessation services.
The Australian government has put in place a number of sound policies to address the problem of smoking and some of them are Tackling Indigenous Smoking (TIS). This initiative aims to lower smoking prevalence amongst the Aboriginal and Torres Strait Islander people through increasing knowledge and appropriate assistance. TIS will target Indigenous Australians because they face distinct barriers to quitting smoking, and the interventions that have been proposed have demonstrated potential in lowering smoking rates among Indigenous Australians (Rahman et al., 2021).
The second key element of the Australian strategy is high taxation on tobacco products, which has been one of the most effective measures for smoking cessation. Australia has high tobacco taxes, and regular excise increases are aimed at making smoking expensive, especially for youths and the poor. In addition to taxation, initiatives such as “Quit Now” have an essential function of informing the public about the risks of smoking and motivating them to quit (Ortis et al., 2021). These mass media campaigns have been most successful when used in conjunction with tax increases and smoking rates have subsequently continued to fall.
Some of the major players in these policies comprise the government health departments that supervise and execute programs such as TIS and the taxation policies. The Australian Government affiliated Public Health Association of Australia (PHAA) calls for comprehensive tobacco control strategies. Indigenous health workers are influential in the development of effective interventions (Dorfman & Krasnow, 2014). Also, the role of non-governmental organizations, community members, and healthcare workers is vital in promoting cessation and influencing the public health policies.
Tobacco control in Australia has been effective in most cases, but some groups are still highly vulnerable to smoking and are likely to experience higher levels of difficulty in quitting. Coping with these disparities is well informed by research-based interventions that are specific to the specific type of disparity.
Banning or restricting the access to tobacco products in stores is one of the most effective interventions in smoking prevention. It has already been used in countries like New Zealand where the government has set up policies to ban tobacco products gradually (David et al., 2020). They include limitation of access to cigarettes through banning of the sale of cigarettes in convenience stores and supermarkets and instead selling cigarettes in tobacco shops and outlets owned by the government. Such measures would reduce the availability of tobacco products especially to the youths and in essence the smoking culture would not be promoted in society.
Studies have indicated that measures that limit access to tobacco products have the potential of lowering smoking rates, particularly among the youths and the less wealthy (Carnazza et al., 2021). Besides banning the sale of tobacco products, supply side intervention could be as follows; – more stringent measures taken against advertising and promotion of tobacco products, – more effective implementation of laws that prohibit the sale of tobacco products to children.
Smoking cession interventions require equity focused and particularly should address Indigenous Australians and people with mental health disorders. Special cessation programs for these group have been found to be more effective than the general ones since they fit the needs of their clients. For instance, the Tackling Indigenous Smoking (TIS) aims at offering culturally appropriate smoking cessation strategies, such as community engagement approaches and individual counselling services (Tane et al., 2022). Increasing the scale of programs such as TIS in order to extend them to other Indigenous communities would contribute to the decrease in tobacco-related burden in these populations.
Interventions targeting equity have also to consider the context in which social determinants of health (SMR) is higher in disadvantaged population (Perry et al., 2022). These include for example poverty, no education and health care, no social contact. Addressing these root causes in turn promotes equity and enables intervention strategies that will facilitate smoking cessation and prevent relapse.
Tobacco control interventions should be incorporated into primary care services especially for the mentally ill and Aboriginal people (Richardson et al., 2020). It has been found that individuals with mental illness are able to quit smoking if they are supported through their mental health care services. Expanding access to smoking cessation services means that more smokers will be able to receive help to quit, if these services are integrated into primary care, hospital and mental health settings. Such services should comprise the use of nicotine replacement products, counselling and check up to avoid backsliding.
Smoking cessation programs should be adapted according to the population, especially the one that has higher prevalence of smoking (Madureira et al., 2020). For instance, programs for Indigenous Australians should be culturally appropriate and implemented by health care professionals who have worked with Indigenous Australians. Likewise, programs for the mentally ill should be incorporated into mental health care and should be provided with continuous care to meet the needs of this special group of people.
Supply side measures coupled with equity oriented strategies provide the best solution to the problem of lowering smoking prevalence in Australia. The measures that would minimize the access to tobacco would include; supply side measures like banning of sale of tobacco products in retail shops which would greatly reduce the accessibility of tobacco products by the youths and the disadvantaged (Hossain et al., 2021). Equity targeted interventions on the other hand would offer assistance in quitting smoking to those most in need such as the indigenous Australians, people with mental health disorders and those in the rural areas.
These interventions would target both the supply and demand sides of tobacco use, thus reducing tobacco use and promoting smoking cessation and preventing future generations from being hooked to the vice. Australia has achieved a lot in the fight against tobacco smoking; however, more efforts are needed if the National Tobacco Strategy (2023-2030) goals are to be met. The measures suggested here, supply side regulation and equity oriented initiatives, present a holistic approach to addressing the problem of tobacco product availability and the social conditions that sustain smoking among high risk populations.
Quitting the tobacco use in Australia requires a comprehensive and aggressive strategy that targets both supply and demand sides. Some achievements have been made, for example, with the national policies such as plain packaging and the National Tobacco Strategy 2023-2030, however, smoking rates among vulnerable populations’ persist.
Supply-side measures including restrictions on availability of tobacco products in combination with equity oriented measures targeting Indigenous Australians, rural populations and people with mental illness are likely to offer the most effective approach to achieving the goal of smoking prevalence below 5% by 2030 (Mills et al., 2022).
This two-pronged strategy not only reduces the availability of tobacco products but also gives much-needed assistance to those who want to quit, especially those from vulnerable backgrounds. The application of these evidence based interventions will go a long way to decreasing health disparities due to tobacco use and thus move Australia closer to a tobacco free society.
Title: Achieving a Tobacco-Free Australia by 2030
Audience: Australian Government, Ministry of Health
This policy position paper calls for Australia to scale up an assertive and inclusive approach to end the epidemic by 2030. Smoking is still the biggest cause of preventable deaths in Australia and it disproportionately affects Indigenous Australians and other minorities, people with mental health problems, and people with a low income. The policy recommendation of this paper is a combination of supply side measures such as restrictions on tobacco sales and demand side measures such as equity focused smoking cessation programs. These interventions are based on research and will underpin Australia's National Tobacco Strategy (NTS) 2023–2030 and enable achievement of the smoking prevalence targets below 5% in the target year.
Tobacco continues to be a major source of health and economic burden to the Australian populace. Smoking kills over 20,000 Australians every year and causes a huge burden to the Australian healthcare system (Gordon & Preston, 2023). The NTS 2023-2030 seeks to enhance one of the greatest concerns of public health which is smoking through intervention. However, specific groups continue to be most affected. Aboriginal people, people living in rural areas, and mentally ill patients also smoke more often and need special approaches to quitting.
The main goal of this policy is to minimize the accessibility of tobacco products and at the same time, provide equal opportunities to quit smoking for vulnerable groups. To enhance the understandability and approval by the public and politicians, this policy needs to be framed in terms of health justice, intergenerational justice and cost savings through health promotion.
Health Equity: This policy aims at the elimination of health inequalities in Australia. Smoking remains a major health issue affecting the most vulnerable populations including Indigenous people, people with mental health problems, and the poor (Buchanan et al., 2021). If this policy is presented as an attempt to level the playing field on health, the government can mobilise voters’ moral compass and assure that nobody is going to be protected from the harms of tobacco.
Protecting Future Generations: It is crucial to frame the policy as protection of future generations. Measures on the demand side will not allow youth to get access to tobacco and therefore will not allow them to get addicted to it. In this way, the government can create a lot of support among parents, educators, and people who care about their health.
Economic Benefits: Smoking has been found to be costly to the Australian health care system and results in lost productivity because of sickness and truancy (Dobson et al., 2020). The positive impact of smoking prevalence reduction on the economy in the long run such as the cost of health care and productivity gains in the workforce can be used to offset the costs of implementing the policy. To these voters, stressing these economic benefits will resonate as a positive message on the economy.
Allies and Champions: Tobacco control advocates, the Public Health Association of Australia (PHAA) and other healthcare professionals can play the role of advocates for this policy (Dorfman & Krasnow, 2014). Another set of stakeholders is Indigenous leaders and mental health advocates who would make sure that the policy is fair for everyone.
Supply side controls would entail prohibition of sale of tobacco in convenient stores, supermarkets and other outlets and restrict the accessibility of tobacco to selective outlets or state owned outlets. This approach has been successfully used in such countries as New Zealand where there are ongoing gradual efforts to eliminate tobacco products from the market to ensure that the young generation does not have access to cigarettes (David et al., 2020).
1. Reduces consumption and use of tobacco products, especially among the youths and other susceptible persons.
2. Prevents quitting by making tobacco more easily available.
3. Reduces smoking in daily activities.
1. Possible resistance from the retailers who may be depending on the sales of tobacco products for their income.
2. Legal cases by the tobacco industry.
3. Needs a lot of policing to ensure that the tobacco is sold in the black market.
Equity focused programs would be directed at population groups that currently smoke at higher rates, for instance Indigenous Australians and people with mental health disorders (Fisher et al., 2022). These programs would include culturally appropriate intervention in terms of counseling, nicotine replacement therapy and follow up according to the need in the population.
Pros:
1. It tackles issues of health inequalities and supports high risk groups to quit.
2. Enhances the prospect of long term abstinence among the vulnerable populations.
3. Enhances health equity since smoking causes several diseases that may be costly to treat.
Cons:
1. This implies a strong investment in the healthcare sector and many resources.
2. May be hard to replicate and maintain across the nation.
3. The success of cessation services is pegged on the availability and accessibility of the services.
The use of mass media campaigns and raising the tobacco taxes have been proved to be efficient in the reduction of smoking (Bafunno et al., 2020). Australia has been able to reduce smoking prevalence across the different groups through taxation and vigorous public health campaigns.
Pros:
1. Proven to decrease smoking prevalence, especially when augmented with taxation.
2. Brings government revenue which can be reinvested in health care and cessation services.
3. Suitable for gaining coverage among a large number of people especially when using mass media.
Cons:
1. It is also a possibility that campaigns will not be able to penetrate the vulnerable groups.
2. High taxes are regressive in that they burden the poor smoker without giving enough incentives to quit.
3. It means that constant investment is necessary to sustain the performance of the campaign.
The best solution is Option 1 (Supply-side restrictions) and Option 2 (Smoking cessation programs for equity populations). This dual approach tackles both the question of access to tobacco products and the problem of tailoring smoking cessation information for disadvantaged groups. Supply side restrictions would go a long way to normalizing smoking and rendering it less easily achievable for the youth while equity based programmes would assist the targeted high prevalence group to quit successfully.
Since the proposed approach is focused on the supply and demand sides of tobacco control simultaneously, this approach will be the most effective approach to reducing the prevalence of smoking and achieving the objectives of the National Tobacco Strategy 2023-2030.
It is important to position the policy as a means for addressing health disparities to gain the support of the government. When the policy is presented as a measure towards health equality, it is a social justice cause for Indigenous Australians and people with mental illness, groups that smoke more than others. Emphasizing that such populations are prioritized in the policy helps to stress the government’s role in combating systematic injustice. Health equity makes the electorate understand the policy is fair and inclusive, making them support it. It means that by stressing that disadvantaged groups will benefit from the cessation support, the government can prove that it will protect all Australians regardless of their status.
Policymakers and voters will be more inclined to support the policy if they are assured that in the long run there will be economic gains. Smoking is a financial drain to the health sector since billions of money is used to treat diseases caused by smoking including cancer and cardiovascular diseases (Boachie et al., 2021). In this way, the government can save billions of dollars in healthcare costs and improve the effectiveness of the workforce by decreasing absenteeism and early retirement because of illness. Presenting the policy as one that is financially neutral or even beneficial to the taxpayers helps to sell the policy, especially given the prevailing economic conditions. Stressing the possibilities of reinvesting these savings into further development of the public health care facilities is yet another appealing factor for the public.
The credibility of the proposed interventions is enhanced by the fact that the success of tobacco control policies can be borrowed from other countries such as New Zealand. New Zealand’s uncompromising supply side controls and targeted quit initiatives have contributed to a large decrease in smoking prevalence (David et al., 2020). In this way, Australia can use these International case studies as a model of best practice in order to promote the country as a leader in public health. Furthermore, the policy is more realistic because the government can borrow ideas from the best practices from other countries and apply them in the region.
The tobacco industry especially has been known to fight most of the public health measures in courts and lobby furiously. The government should expect such opposition and remain ready with the evidence of its past successes in countering industry backlash, for instance, plain packaging, and restrictions on advertising. When the policy is presented as part of the ongoing fight for public health in Australia, the government can draw from previous successes, which will help to counter industry pressure. Also, stressing that many of the respondents favoured more stringent regulation can counter industry claims and enhance the policy’s political appeal.
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