Improving tobacco cessation rates in priority populations

The implementation of consistent and comprehensive approaches to tobacco control by Australian governments since the 1970s resulted in major reductions in population smoking rates. Decades of policy reforms, including regulation of cigarette advertising and sporting sponsorship; tobacco excise increases; implementation of comprehensive smoke-free legislation and the more recent plain packaging of cigarettes, combined with mass media campaigns, have substantially reduced the national average smoking rate. It has declined from 36% of the adult population in 1977 to 19% in 2007 to 11% reported in the 2019 National Drug Strategy and Household Survey.

Although death rates from diseases attributable to smoking tobacco (for example, lung cancer, coronary heart disease and stroke) have declined over the past thirty years, smoking remains the single leading cause of preventable death and disease and one of the leading causes of preventable healthcare costs in Australia. In the 2015/2016 year in Australia, there were just over 20,000 “premature deaths attributable to smoking”. In addition, smoking contributed to at least 46 medical conditions requiring treatment and care, 41% of respiratory diseases, 22% of cancers and 12% of cardiovascular disease, and was responsible for 9.3% of the overall burden of disease and injury. Tobacco smoking causes more ill-health, hospitalisations and premature death than alcohol and other drug use combined.

A study by the National Drug Research Institute on the social costs of tobacco use in Australia in 2015-16 estimated the full cost of the burden from tobacco smoking to society in the financial year at $136.9 billion, with some of the costs borne now being a legacy of smoking habits in preceding decades. Of the estimated costs in 2015-16, only $5.5 billion was identified as the cost of tobacco to smokers. The total costs included a combination of tangible and intangible costs, from nearly $4 billion in primary healthcare treatment, hospital inpatient and outpatient treatment, ambulance and emergency department treatment, to costs associated with ill-health and premature death such as loss of productivity, unpaid caring by family members, smoking litter removal and fire damage caused by cigarettes and butts.

The current national smoking prevalence of 11% represents just over 2.8 million Australian adults who reported smoking daily in 2019. The National Preventive Health Strategy 2021-2030, released in 2021, has set a new national target of 5% or less for adults (≥18 years) smoking prevalence by 2030. To achieve this target, more people who smoke need to be supported to quit together with policy emphasis on encouraging former smokers and never-smokers to remain as non-smokers.

There are population groups within the remaining 2.8 million daily smokers with smoking rates well above the national average. These groups often face additional challenges and barriers in successfully quitting smoking. To continue to reduce higher rates of prevalence in these population groups it requires a strong focus on supporting individuals to quit and discouraging the take up of smoking within these groups. Generally referred to as ‘priority population groups’, these groups are often characterised by low-socioeconomic status and/or by other combinations of disadvantage, vulnerability or health risk. Priority population groups include Aboriginal and Torres Strait Islander people, people with mental health conditions, people identifying as gay, lesbian, bisexual, transgender or intersex and people in rural and regional communities.

Peer-reviewed evidence suggests that health networks generally are an underutilized whole of population intervention with the capacity to reach all smokers, reinforce the importance of quitting and connect individuals to smoking cessation resources appropriate for them in a cost-effective way. Priority population groups are more likely to have poorer health than the general population and to have more frequent contact with health services. Leveraging these interactions with health care provides an efficient and effective means to engage with smokers and facilitate smoking cessation support.

This paper also considers the role of tobacco related products in promoting and sustaining cigarette smoking and other tobacco consumption. Filters in cigarettes are thought by some smokers to offer protection by filtering out harms despite the evidence to the contrary. In addition, filters with flavour capsules entice and initiate young people into smoking behaviours who often assume (incorrectly) these products are less harmful [20]. Strong evidence connects filters to a range of health risks. In response, there is an emerging view that there is potential for significant positive impact through the banning of filters in cigarettes. Policy reforms of this nature are under consideration in New Zealand and New York state. Until further evidence is available following the implementation of these reforms, educational campaigns on the harms of filters could be an effective intervention.

There has been rapid growth in e-cigarette use by adolescents and young people. This has the potential to reverse the downward smoking prevalence trends in this group. Reducing affordability of and access to these products could be expected to reduce the take up of smoking by teenagers. A national licensing scheme could strengthen tobacco controls and support whole of population smoking reduction.

Finally, this paper reiterates the importance of maintaining and strengthening whole of population anti-smoking interventions, such as policy frameworks and investments, regulation and mass media/social marketing campaigns, that reinforce and normalize non-smoking in society. Characteristic for whole of population health interventions is the focus on addressing underlying conditions. Such a strategic and sustained approach sets a strong foundation that encourages all smokers to quit, helps prevent relapse in those who have quit and discourages the uptake of smoking particularly for young people. Where whole of population interventions are mass media campaigns, the evidence indicates they must be purposefully inclusive of priority populations to support maximum reach into these groups. Previous Australian programs have shown that impact is magnified when these communities are engaged in identifying how existing resources might be better tailored to them and development of any other additional supports.

This policy evidence brief outlines:

• the groups within the Australian population with high smoking prevalence rates and some of the additional barriers that they need support to overcome
• interventions that, when combined, create an effective foundation to support existing smokers, particularly those in priority populations, to quit, discourage relapse and encourage young people to never smoke
• effective interventions that use existing health resources, where available
• policy options that will best support the achievement of the national aim for 5% or less for adults (≥18 years) smoking prevalence target by 2030.

The policy options include:

• re-commencement of mass media campaigns ensuring that they:
  • are inclusive of priority populations and reflective of their challenges
  • educate about product engineering such as the harms of filters and e-cigarettes.
• investment in optimising all interactions between smokers and healthcare, both primary and specialist, to embed a health focus on smoking cessation and support through incentives and investments in evidence-informed treatment approaches, including combined pharmacotherapies with behavioural interventions, with training and support for healthcare professionals
• establishment of a national retail tobacco sales licensing scheme.