Reaching everyone: tobacco control must remain a health priority

The most important and striking implication of the article by Aw and colleagues in this issue of the MJA1 is that tobacco control must remain a population health priority. The wide ranging policies and programs that reduced the population daily smoking rate in Australia to 11% by 20192 must be maintained and expanded to meet and ideally surpass the National Tobacco Strategy 2023–2030 goal of 5% or less by 2030.3 There is no room for complacency: despite the progress made, smoking has caused more than 500 000 deaths in Australia since the turn of the century, as noted by Professor Emily Banks in her testimony to the Senate Community Affairs Legislation Committee in late 2023.4 We have long known that reducing smoking rates requires a comprehensive, adequately funded approach. But continuing action and vigilance is required in the face of a global industry determined to continue promoting and selling addictive products for commercial gain.

As population smoking rates hover around 10%, it can be tempting to think that the focus of tobacco control should shift to targeted programs that offer intensive support to specific groups of people who wish to quit smoking. Anyone who smokes should have ready access to suitable and effective cessation support, but this help should be a crucial component of, not a replacement for, population‐level strategies. Reducing health inequities linked with smoking must also remain a key component of our programs. The highly successful Tackling Indigenous Smoking program exemplifies a community population health promotion approach that also includes improved access to targeted support for quitting.5

Emotive health messages are an excellent example of what can effectively reduce smoking rates, motivating people who smoke to attempt quitting6 and discouraging people from commencing smoking.7 However, Australian cigarette packet warnings have not changed for more than a decade since we led the world with plain packaging laws, and there have been no recent major national media campaigns. As a welcome part of an overall parcel of new reforms announced in December 2023, health warnings will finally be refreshed with new and diverse messages, accompanied by new media campaigns.8 This is an evidence‐based population health approach that reaches everyone and offers opportunities to provide new and relevant information to different groups of people who smoke. While, as noted by Aw and colleagues,1 many people who smoke report being in good health, the health impacts of smoking generally develop over years of use: reminding people about and increasing the salience of its long term health impacts is vital for encouraging attempts to quit.

A further reason to focus on population programs rather than targeting specific groups of people who smoke only is to avoid framing tobacco use as primarily a personal responsibility. Tobacco products are designed, manufactured, marketed, and sold by multinational companies that have exploited government inaction and addicted and killed millions of people around the world. We agree wholeheartedly with Aw and colleagues1 that regulating and holding the tobacco industry accountable is essential for effective tobacco control. Further, it should be complemented by strict regulation of vaping and related products, with a strong national strategy based on medical prescription access for smoking cessation purposes only.

While the recent reforms announced by the Australian Minister for Health and Aged Care will further curb tobacco company marketing and require reporting on product details and sales,8 the industry will for the foreseeable future still be permitted to sell its deadly products in every community. There is increasing global momentum toward disrupting how tobacco products are sold, but also disturbing evidence of continuing lobbying by tobacco product manufacturers to undermine these advances. The New Zealand ban on the sale of tobacco products to anyone born since 2009, together with significantly reducing the number of tobacco retailers, was widely acclaimed.9 However, following the 2023 election, the incoming government announced plans to repeal these measures; the Finance Minister even noted that this would increase taxation revenue for the government.10 This type of cynicism with respect to tobacco is widely condemned by the global public health community.11

After many years working in tobacco control, we often hear that “no one really smokes anymore” or that “junk food/gambling/alcohol is the new smoking.” The article by Aw and colleagues1 paints a humbling picture: tobacco use continues to have devastating consequences across Australia, and people who smoke cannot be typecast, being found in all parts of the community. The health impact of tobacco use still urgently warrant both highly targeted initiatives that empower underserved groups of people and population‐wide strategies that reach everyone.

The glass is half empty: more than seventy years since we learned that smoking kills, it remains our largest preventable cause of death, and we face the twin challenges of complacency and a resurgent global tobacco industry. But the glass is also half full: we have overcome such obstacles before, and we know what needs to be done. We should not be distracted by the tobacco industry and its allies or by debates about which components of the strategy are more important. We need a strong, comprehensive, adequately funded approach that prioritises equity and reaches the entire community.11