7.9 Policy measures associated with quitting
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7.9.1 Taxation/pricing
Increasing the price of tobacco products through raising taxation (excise) has been a major public health strategy for decades. The income raised ($5.38 billion in 2006–7) makes this a popular strategy with governments, but it is also effective in driving down consumption through discouraging uptake, reducing the number of cigarettes purchased by established smokers, and encouraging quitting.44, 201 In Australia, excise and customs duty on tobacco products is adjusted regularly in line with Consumer Price Index rises, maintaining prices in real terms. In July 2000, in the period immediately after a price increase due to the introduction of GST, the Quitline received a modest increase in calls for assistance in quitting.202
High prices are especially important as a deterrent for young people's uptake (as they tend to have less disposable income) and for adults with low income (even though they are most likely to be smokers—see Chapter 9). A 10% increase in price across the world in 1995 would have reduced the number of smoking-attributable deaths by a conservative five to 16 million, mostly in poor and middle income countries.203 In rich countries, a price increase of 10% would be predicted to reduce smoking deaths by between 0.7% and 3%.203 Taxation must be used as part of a comprehensive approach, involving provision of cessation assistance, because there is a risk of increased hardship among low-income smokers who have difficulty quitting.
7.9.2 Smokefree areas
Over the past two decades, most workplaces in Australia have become smokefree, initially through fear of litigation, and then by legislation which has recently been extended to cover most bars and most gaming areas.204, 205 Private homes are now increasingly banning smoking inside on a voluntary basis for both resident smokers and visitors. A significant factor in this decision is the presence of children in the home.206 For example, the proportion of homes with children aged four years and under reporting a complete indoor smoking ban in South Australia has risen from 60% in 1998 to 78% in 2005.207
An assessment of the evidence for the effectiveness of smokefree policies found that smokefree workplaces decrease cigarette consumption in continuing smokers. There is strong evidence that smokefree workplaces decrease the prevalence of adult smoking.208 In a study of the Australian Public Service, the average number of cigarettes smoked reduced by about three to five cigarettes per day after the introduction of bans, with heavier smokers reducing more.209, 210
The introduction of smokefree bars, nightclubs and gaming venues in Victoria resulted in reduced consumption among one-third of smokers, and 40% of recent quitters reported that the smoking ban had helped them quit.211 Smokefree venues especially influenced cigarette consumption by young people who, before the smoking ban was implemented, nominated bars and nightclubs among the places where they smoke most.211, 212 International research has shown an increase in quit attempts resulting from such laws,213 and an increase in calls to a Quitline.214
A study including Australian participants found that household bans have a modest effect on increasing quit rates, reducing relapse, and reducing the amount smoked by resident smokers.215 This research concurs with international research and a major international review that found that smokefree home policies decrease adult smoking. 208 Total and partial household smoking bans increase quitting attempts around four-fold (3.86) and two-fold (1.83) respectively.216 In addition there is strong evidence that public and workplace smokefree policies and smokefree homes decrease smoking in youths.208, 217
7.9.3 Pack warnings
The introduction of graphic pictorial pack warnings in Australia in 2006 has increased the range and impact of information confronting smokers each time they reach for a cigarette. Such messages have been shown to result in increased thoughts about quitting and these are associated with subsequent attempts to quit.218–220 The new warnings contain more information about the health consequences of smoking than previously, and all include the telephone number for the Quitline, with the intention of prompting smokers to take action.
Like any message repeated often enough, the warnings are likely to lose some of their impact over time,221 so it is important to ensure the content and style of such warnings is refreshed regularly to maintain effectiveness.
7.9.4 Mass media campaigns
Mass media campaigns, also called social marketing campaigns, can be delivered through a variety of channels of communication including television, radio, newspapers, billboards, posters, leaflets, booklets or the internet. They are intended to reach large numbers of people without depending on person-to-person contact. A major review of mass media interventions for smoking cessation in adults reached the conclusion that 'it is likely that they contribute to a reduction in smoking when used as part of a complex set of interventions, but it is difficult to establish their independent role and value in this process.'222
In Australia, promotion of the Quit and Smokefree messages through mass media campaigns is a key component of the National Tobacco Strategy 2004–2009. A substantial body of research studying the impact of the National Tobacco Campaign (1997–2001) on the Australian population supports the use of mass media campaigns to promote quitting and the use of the Quitline. Tracking surveys showed that the campaign reached the majority of its target group, increased awareness of the health effects of smoking, influenced attitudes to smoking and thoughts about quitting, and drove calls to the Quitline.91, 223–226 About half of smokers reported that the campaign made them more likely to quit, and a similar proportion of ex-smokers believed that it had helped them stay quit.223 A survey tracking the monthly changes in Australian smoking rates from 1995 to 2006 found that exposure to tobacco control media campaigns significantly reduced smoking prevalence, with increases in the levels of exposure related to declines in smoking.227
Anti-smoking television advertising is the most frequently mentioned source of help contributing to the quit attempts of people who have recently quit.2, 228, 229 The effectiveness of campaigns is mediated by the message, creative execution and scheduling weight of advertising (TARPS).224, 225, 230–232 Smokers and ex-smokers who tend to become absorbed in a narrative are more likely to perceive advertising as helpful.231 Smokers who engage in discussions with family or friends about anti-smoking advertising are more likely to have made an attempt to quit or intend to quit in the future.231, 233
For more details on the history and progress of Australian tobacco control campaigns and how they work, refer to Chapter 14.
7.9.5 Funding for cessation programs
Like most health matters, financial responsibility for smoking cessation is split between the Commonwealth and state and territory governments. The Commonwealth, states and territories have varied considerably in the amount of funding and priority given to promoting cessation and other tobacco control measures. Non-government organisations such as the Australian Medical Association, National Heart Foundation and Cancer Councils have consistently lobbied for increased effort by all governments. For example, less than 1% ($3.6 million) of the total tax raised from smokers was spent on tobacco control measures by the Australian government in the financial year 2005–06.234 A model policy of $10 per head of population or 1c per stick of tobacco sold for tobacco control, split between national and state governments has been proposed, but there is a large gap between current funding and this target.67
Bupropion, marketed as Zyban SR, Clorpax, Prexaton and Bupropion-RL, was listed on the Pharmaceutical Benefits Scheme (PBS) in February 2001 and varenicline, marketed as Champix, in February 2008, but nicotine replacement therapy is not included on the PBS. By the end of June 2008, total PBS subsidies for bupropion totalled at least $140 million, nearly half of this in the first year.235
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