The mortality rate from tobacco-related disease remains inordinately high, with one Australian death every 30 minutes.¹ Hill, White and Scollo, in this issue of the Journal, report smoking rates of Australian adults for 1995 and look at trends in smoking prevalence over time.² The 1995 figures show that, compared with the previous uniformly downward trend in smoking prevalence in Australia, there has been a disturbing stabilising in prevalence of smoking in both men and women.

For other countries, comparative 1995 data are sparse, and, high mortality rates notwithstanding, Australian (and New Zealand) smoking rates are among the lowest on the international ladder, together with those of Sweden, Finland, the United Kingdom, the United States (especially California), and a small number of other exemplar countries or States. The average smoking rate for this group is about 25%-30% or less,³ and consistently measured data are available over a considerable period.

Despite their similar smoking patterns, the countries and environments in which lower smoking rates have been achieved differ remarkably, making generalisation about the most effective tobacco control policies perilous.

• Australia began with health warnings in the early 1970s, and a patchwork quilt of State and federal laws to control advertising, which evolved (amid much controversy) into good, but not perfect, comprehensive federal legislation in 1992, with final implementation achieved only in 1996. We also have good research-based education programs.

• Finland and Sweden have had comprehensive legislation in place for two decades (which cannot, of course, prevent cross-border advertising) and have backed this up with competent education programs.

• California has spent very large amounts of money in recent years on well researched antismoking campaigns, which have been competing with vigorous and clever tobacco advertising (only radio and TV advertising is banned). At present, antismoking campaigns are being conducted amid enormous public debate.⁴ Mean smoking prevalence in 1995 was 16.7%.⁵

• The United Kingdom can be best classified as having modest advertising controls and modest education programs.

Although implementation of tobacco control policy has been somewhat erratic, there is historical and international agreement⁶ on the necessity for a comprehensive approach (including comprehensive legislation) which prohibits all forms of tobacco promotion, conducts public education campaigns, implements programs to help smokers to quit, restricts smoking in public places and sales to minors, and regularly increases prices. More recently, the emphasis has been on smoke-free workplaces, generic packaging and banning point-of-sale promotions.

Probably the only generalisations possible are that no country has been successful in shielding its population from all tobacco advertising and that no country has consistently spent commercially large amounts of money on education over a significant period of time (such as amounts spent by Coca-Cola -- $30-$35 million nationally in Australia⁷ -- or the Victorian Traffic Accident Commission -- $24 million⁸).

Meanwhile, the resilient and resourceful tobacco industry has responded to tobacco control by focusing increasingly on cross-border and global advertising and global brands. A topical example of global advertising -- Formula One car racing -- is illustrative. Excluded from the Australian prohibition on television and radio advertising in 1975 by a last-minute amendment⁹ which opened a suitable loophole, Grand Prix racing is still favoured by specific exclusion in 1998. Winfield, which otherwise may be advertised only at point of sale in Australia, is to be launched as a global brand in 1998 through Formula One, and will therefore be advertised back into Australia, as well as globally, by this means. One can only marvel at the tobacco industry's advertising ingenuity¹⁰ in using the kangaroo symbol, placing it on the red background of the new packet, and incidentally turning Qantas tailplanes into surrogate Winfield advertisements. Continued broadcasting of the tobacco-sponsored Grand Prix from the United Kingdom will occur until the year 2006. This decision was preceded by a controversial pre-election gift of £1 million to the British Labour Party by the key promoter of the Formula One Grand Prix,¹¹ a feat which the public health fraternity will have difficulty matching.

The Australian situation is indeed serious, and, as with the other developed industrialised countries mentioned, prevalence averages conceal both the better and the worse aspects of smoking habits -- all these countries have the same education and occupation gradients. Regardless of how impressive the low smoking prevalence of 18.7% (16.7% for women) is among the highest occupational level of Australian households, it is profoundly depressing to observe the prevalences of 40.9% and 31.8%, respectively, for the lowest occupational level, even though these blue collar levels have seen quite large falls over time.

Clearly more effort is needed. Hill et al collated data on smoking prevalences and antismoking campaigns and found that the levelling off in previously declining prevalences is related to lower per capita expenditure on antismoking campaigns. The solution, in essence, requires renewed action on two major interrelated fronts. One is money; the other is legislation.

Money need not be a problem. The popular principle of allocation of tobacco tax for health promotion purposes was established by the Victorian Tobacco Act 1987 (a world first), which established the Victorian Health Promotion Foundation (VicHealth). Similar Acts followed in Western Australia and South Australia. The original mandate of VicHealth included spending 30% of its then $28 million budget on sport, plus significant amounts on arts sponsorship and outdoor advertising, to buy out and replace the vested interests then advertising tobacco. This is no longer necessary, as federal legislation now consolidates advertising prohibition in these fields. As a consequence, in 1997, the Victorian Quit campaign received 10% of VicHealth's $23 million.

Australian tobacco tax is low by UK and Scandinavian standards and should be increased. Lifting the Victorian Quit allocation from under $3 million to $12 million would equal about $3 per head of population, and would cost less than a packet of cigarettes per head. If followed by other States and matched by 1997 level federal expenditure a serious national campaign could be mounted.

State (and possibly federal) tobacco legislation now requires rewriting, both because State tobacco licence fees have been declared unconstitutional and because national competition policy requires it.¹² So, 1998 offers a golden opportunity to rewrite the prescription, and some evolutionary legislation is indeed timely:

• Generic packaging should be introduced;

• Sales to minors should be more effectively restricted and the restrictions implemented;

• Point-of-sale advertising should disappear; and

• Exemptions for international sporting events should be phased out over time, preferably in conjunction with similar action in the United States and Europe.

Finally, enough is now known about nicotine-driven compensatory smoking¹³ and differential carcinogen levels in cigarette brands¹⁴ to legislate for control of nicotine content and to introduce, and progressively reduce, upper limits for specific carcinogens.

New tobacco legislation is needed in 1998-99. It should be about tobacco, its control and the proper funding of programs to reduce its use and effects. Smoking prevalence and tobacco disease should then continue to decline.

Nigel J Gray
Consultant European Institute of Oncology, Milan, Italy

1. English DR, Holman CDJ, Milne E, et al. The quantification of drug caused morbidity and mortality in Australia. 1995 edition. Canberra: Commonwealth Department of Human Services and Health, 1995.
2. Hill DJ, White VM, Scollo MM. Smoking behaviours of Australian adults in 1995: trends and concerns. Med J Aust 1998; 168: 209-213.
3. Tobacco or health: a global status report. Geneva: World Health Organization, 1997.
4. Gray N. The global settlement -- a global view [editorial]. J Surg Oncol 1997; 66: 79-80.
5. Glantz SA. Tobacco control in Australia: it's time to get back on top down under. Health Promot J Aust 1997; 7(1): 72-73.
6. Gray NJ, editor. Lung cancer prevention: guidelines for smoking control. Geneva: Union International Contre le Cancer, 1997.
7. Business Review Weekly 1997; Feb 7: 73.
8. Victorian Traffic Accident Commission, Annual Report, Melbourne: VTAC, 1997.
9. Gray NJ. Forty years of plotting for public health. Med J Aust 1997; 176: 587-589.
10. Toy M-A. Outrage as Rothmans plans kangaroo label on cigarettes. The Age (Melbourne) 1998; Jan 17: 1.
11. Morrison J. Row blights Blair's honeymoon. The Sunday Age (Melbourne) 1997; Nov 16: 15.
12. Colebatch T. States' $5b tax rescue plan. The Age (Melbourne) 1997; Aug 6: A.1.
13. Kozlowski LT, Ricket WS, Pope MA, et al. Estimating the yields to smokers of tar, nicotine and carbon monoxide from the lowest yield ventilated filter cigarettes. Br J Addict 1982; 77: 159-165.
14. Hoffmann D, Hoffmann I. Tobacco consumption and lung cancer. In: Hansen HH, editor. Lung cancer. Advances in basic and clinical research. Dortrecht: Kluwer Academic Publications, 1994: 1-42. o

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