Smoking remains the leading cause of preventable death globally. Each year 7.1 million people who smoke will die from diseases caused by smoking, and an additional 1.2 million people will die from exposure to second hand smoke. In Australia, smoking causes nearly 1 in 7 deaths and 9% of the disease burden. Currently, around 2.3 million Australians smoke tobacco daily.
These statistics, and the sustained harm from smoking, have given rise to discussion of how to end the cigarette epidemic. Often described as ‘the tobacco endgame’, this goal means permanently reducing overall smoking prevalence to a minimal level within a defined timeframe. Previously defined endgame targets include: close to zero smoking prevalence (ranging from <1% to <5%), ending tobacco sales, eliminating smoking disparities, and eliminating children’s exposure to smoking. The Australian government’s current goal of 10% smoking prevalence by 2025 falls short of being an endgame target. However, Australia is ideally placed to develop a tobacco endgame strategy, being one of few countries to achieve a daily smoking prevalence under 15%, which has been proposed as the critical point when an endgame becomes politically feasible.
A range of endgame strategies have been described, some of which have been partially implemented or are under serious consideration in other countries, including regulating the content and emissions of tobacco products to make them non-addictive, less palatable, and removing the most harmful products from the market entirely. Proposed supply reduction strategies range from reducing the number of tobacco retailers, restricting sales to particular categories of suppliers (e.g., pharmacies), ending sales to everyone born after a certain year, phasing out commercial cigarette sales and regulated markets or non-profit supply models.
Australia is a global tobacco control leader and been at the cutting edge of many new policies. Australia was the first country to mandate plain packaging for tobacco products, now in place or being implemented in 17 other countries. Similarly, Australia and New Zealand are at the forefront of tobacco tax policy with cigarette prices among the world’s highest, due to a series of substantial tobacco tax increases in both countries (25% in 2010 and 12.5% annually from 2013 to 2020 in Australia, and 10% annually in New Zealand from 2010 to 2020). Additionally, Australia has led on prioritising Indigenous-specific smoking reduction measures, such as the Tackling Indigenous Smoking Program, which provides a foundation to build on to reach more Indigenous Australians with effective tobacco control and smoking cessation interventions. While Australia has done well, additional approaches and innovations are needed if we are to achieve an equitable tobacco endgame.
An effective tobacco endgame strategy should accelerate the decline in smoking prevalence while assisting governments, retailers and people who smoke to transition to a smokefree society. People who smoke will need support to quit, and ensuring that endgame approaches reduce, rather than exacerbate, disparities in smoking prevalence will be critical. Ensuring Indigenous knowledges, peoples and leadership are engaged in the development of an endgame strategy will be essential to produce inclusive, equitable, and effective approaches.
The new NHMRC Centre of Research Excellence on Achieving the Tobacco Endgame (CREATE) aims to develop the evidence base for endgame strategies and will identify the most promising strategies that could end the cigarette epidemic in Australia, and beyond. CREATE brings together a multidisciplinary team of experts in health policy, behavioural science, epidemiology, biostatistics, law, health economics, Indigenous health, environmental health, psychology, and mental health and substance use disorders from institutions in Australia, New Zealand and Canada. CREATE’s four research programs will: 1) estimate the health and socioeconomic impacts of proposed endgame strategies through epidemiological research and modelling, 2) develop a legal framework for the implementation and defence of tobacco endgame strategies and review relevant case studies, 3) engage with stakeholders to understand positions, viewpoints, preferred policy options, and concerns, and 4) identify potential unintended adverse impacts and design strategies to mitigate these including how to best support people to stop smoking.
CREATE’s ambitious goal is to determine the optimal mix of strategies that will help Australia become a smokefree nation and produce a roadmap outlining how to implement these strategies, while mitigating potential unintended impacts and increasing equity. CREATE also aims to inform strategies that could catalyse reductions in low and middle-income countries, where tobacco companies are now focusing their marketing efforts. Furthermore, CREATE will help equip the next wave of public health research leaders to address the commercial determinants of health (e.g., selling processed food and drink, alcohol, and tobacco), which are key drivers of the global burden of non-communicable diseases. Australia is already a world-leader in public health initiatives. Creating a strategy to realise the tobacco endgame would move that leadership to a new level and bring global health benefits.
This blog is an extract of a full article published by MJA InSight+.
Written by UQ School of Public Health Associate Professor Coral Gartner on behalf of the CREATE Investigator Team:
Associate Professor Coral Gartner, Dr Gary Chan (The University of Queensland)
Professor Billie Bonevski, Professor Amanda Baker, Professor Adrian Dunlop (The University of Newcastle)
Professor Tony Blakely, Professor Ron Borland, Dr Cathy Segan (The University of Melbourne)
Raymond Lovett, (Australian National University)
Matthew Rimmer (Queensland University of Technology)
Dr Michelle Scollo (Cancer Council Victoria)
Professor Michael Farrell (University of New South Wales)
Professor David Thomas (Menzies School of Health Research)
Richard Edwards, Janet Hoek, Andrew Waa (The University of Otago, New Zealand)
Natalie Walker (The University of Auckland, New Zealand)
Geoff Fong, David Hammond (The University of Waterloo, Canada)