Reigniting tobacco control: returning Australia to the front of the pack March 2023, Volume 33, Issue 1

Falling to the back of the pack

Understandably, the last few years of public health action – globally and in Australia –have been overwhelmingly focused on the coronavirus disease 2019 (COVID-19) pandemic. The costs of this singular focus include stalled momentum in chronic disease prevention policy innovation. Modernising our approach to preventive health and ensuring that policies, practices, research, and funding match the actual determinants of health is crucial. Not only have governments been asleep on chronic disease, but commercial actors – alcohol, tobacco, gambling, fast food – have seized the opportunity to exploit this lack of focus at the expense of public health.¹

Australia has long been heralded as a leader in tobacco control, but more than 10 years have passed since we implemented the world’s first tobacco plain packaging reforms.² A sense of complacency had already set in well before the outbreak of COVID-19.³ Tobacco control was in the dangerous territory of being considered “done” – despite 14% of the population aged over 14 years still currently smoking in 2019, and smoking remains the single most important preventable cause of ill health and death in Australia.⁴ While tobacco taxes continued to increase during this 10-year pause, very little other national activity occurred. While some musicians can dine out on a greatest hits album for decades, most fade into obscurity without new material.

Reignited action

In late November 2022, the Australian Federal Government announced it would be “reigniting the fight against tobacco addiction with new measures.”⁵ Currently, Australian tobacco control measures are spread across a confusing number of laws, regulations, and voluntary agreements. The announced reforms aim to bring these disparate pieces of legislation together under one Act of Parliament. In much more exciting news, this reform package proposes introducing 11 new tobacco control measures. While the details of all 11 areas of reform have not yet been publicly released, the announcement included a snapshot of some of the approaches we can expect to see, including:⁵

• Updating graphic warnings on tobacco products (these have not been refreshed since 2012)
• Requiring individual cigarettes to be manufactured in unattractive colours or with printed warnings such as “smoking kills”
• Standardising the size of tobacco packets and products
• Preventing the use of specified additives, including flavours and menthol
• Mandating the design and look of filters
• Limiting the use of appealing names on products that falsely imply these products are less harmful, such as “organic” or “light”
• Requiring health promotion inserts inside packs
• Updating advertising regulations to capture e-cigarettes
• Requiring tobacco companies to be transparent about their sales volumes and pricing, product ingredients and emissions, as well as their advertising, promotion and sponsorship activities.

An overarching theme of these expected reforms is that they further limit the ability of the tobacco industry to manufacture and promote products that are attractive and appealing to young people. For example, manufacturers will likely no longer be able to insert flavour beads in filters that increase cigarette novelty and palatability. The reforms will also introduce a higher degree of mandated tobacco industry transparency and reporting that has the potential to make further reforms faster and more responsive.⁶ Public health is always lagging behind tobacco industry marketing and sales innovations. Requiring the industry to fully report its marketing activities, rather than spending time and resources trying to track these activities, is far more efficient. Ensuring that laws regulating tobacco and e-cigarette, advertising, sponsorship, and promotion are up to date with modern marketing methods, including industry use of social media channels, must also be part of these changes.⁷

While the Government announcement did not specifically mention limiting where and how and to whom tobacco products are sold, the door to include reforms targeting these “supply-side initiatives, remains open. In addition to this legislative review, the National Tobacco Strategy 2023–2030 was endorsed by Health Ministers in February 2023, and includes targets to reduce daily smoking prevalence in Australia below 10% by 2025 and to 5% or less by 2030. ⁸  Strengthening regulations to reduce the supply, availability and accessibility of tobacco products was included as one of 11 key priority areas in the draft strategy.⁹  While the endorsement of the Strategy is important, the Government will need to fully fund it to successfully achieve its goals. Bold tobacco supply-side reforms, including increasing the legal age for purchasing tobacco products and dramatically reducing tobacco retail outlets, are currently being implemented in New Zealand.¹⁰ A bit of healthy competition across the Tasman to see just how quickly smoking rates can be cut when multiple, comprehensive, bold measures are enacted is very welcome.

Vaping disruption

Ten years ago, when Australia fought multiple legal challenges from the tobacco industry and established plain packaging as a standard in effective public health action¹¹, e-cigarettes were a fringe issue with little presence in Australia. This is not the case today. The use of e-cigarettes or vaping by young people has skyrocketed during the COVID-19 pandemic.¹² Predatory retailers, manufacturers, and importers have exploited loopholes in e-cigarette regulation and flooded the market with illicit products that appeal to young users. Young people can easily access and prefer flavoured, disposable, inexpensive vaping products that contain nicotine.¹³

When taken at face value, Australia should have one of the most effective regulatory models for protecting young people from taking up vaping. To legally access nicotine-containing vaping products in Australia, users must have a valid prescription from an Australian medical practitioner and use the product to quit smoking. However, because non-nicotine-containing vaping products fall outside the prescription access requirements, they can be freely imported and sold online or at retail outlets. Users have continued to obtain nicotine-containing products because manufacturers either simply fail to label them as containing nicotine or falsely claim they are nicotine-free. Distinguishing between a legal non-nicotine vaping product and an illegal nicotine-containing device requires laboratory testing, which hamstrings effective enforcement of the regulations.

Recognising that the current approach to e-cigarette regulation is not achieving its aim of preventing children and adolescents from accessing vaping products, the Australian Therapeutic Goods Administration (TGA) also launched a consultation on potential reforms in late November 2022.¹⁴ This consultation closed on 16 January 2023, and is reported to have received more than 4000 submissions.¹⁵  Australia’s Health Ministers also agreed in February 2023 to establish a national E-cigarette Working Group, to review and advise on measures to protect young people from the harms of increasingly available e-cigarettes. ⁸

The ideal public health solution would see the elimination of all vaping product sales, nicotine-containing and non-nicotine alike, that fall outside of the TGA prescription pathway.¹⁶ Stopping the importation of all vaping products into Australia, regardless of nicotine content, unless bound for a pharmacy, would simplify and increase the effectiveness of enforcement and stop the flood of illicit products. This would also end young people’s easy access to vaping products and enhance the prescription model to ensure all smokers who use e-cigarettes to quit also receive smoking cessation support from health professionals.

Conclusion

After 10 years of minimal action, it is invigorating to have three key initiatives in play to fully “reignite” tobacco control – the tobacco legislation renewal and update, the national strategy release, and the TGA consultation on the regulation of vaping products. No doubt, the tobacco industry and its allies will continue to interfere in public health policy-making to block, water down, and delay these reforms. The Australian Government must be vigilant in upholding its obligations to protect public health from the tobacco industry’s vested interests, as required under Article 5.3 of the WHO Framework Convention on Tobacco Control.¹⁷ Addressing the commercial determinants of health has taken a back seat during the COVID-19 pandemic, and the Australian Government has been caught off guard by an aggressive industry that seeks to undo decades of effective tobacco control. It is time to return to the front of the pack.

Acknowledgements

BF is an Expert Advisor to the Cancer Council Tobacco Issues Committee and a member of the Cancer Institute Vaping Communications Advisory Panel. These are unpaid roles. She has received relevant research grant funding from the National Health and Medical Research Council, Healthway, and the Medical Research Future Fund. BF is a PHRP Editorial Board member and Associate Editor but had no involvement in the review process for the manuscript.

Peer review and provenance

Externally peer reviewed, not commissioned.

Copyright:

© 2023 Freeman B. This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Licence, which allows others to redistribute, adapt and share this work non-commercially provided they attribute the work and any adapted version of it is distributed under the same Creative Commons licence terms.