Messages about climate, pollution and social justice harms of tobacco as motivators to quit: an untapped communication opportunity?

BACKGROUND: Campaigns highlighting the health harms of smoking have demonstrated success in motivating people who smoke to quit. Tobacco production and use also exert a toll on the environment, sustainable development and human rights. However, messages highlighting these harms of tobacco have been relatively unexplored as a cessation motivation strategy. In this study, we examined the extent to which a range of messages about climate, pollution and social justice harms of tobacco are perceived as motivating among people who smoke, overall and by sociodemographics. DATA AND METHODS: Australian adults who smoke (n=395) aged 18-59 years reported the 'extent to which each of the following motivated them to quit smoking' and were then presented with messages about climate (four items), pollution (three items) and social justice (three items) harms of tobacco, which they rated on a 5-point scale ranging from 1 'Not at all' to 5 'Very much so' in this online cross-sectional survey. Differences by age, education, gender, socioeconomic status (SES) and geographical region were examined using prevalence ratios from generalised linear models with log-link (Poisson regression). RESULTS: For each of the 10 messages, between one-half and two-thirds of the overall sample perceived them as motivating (49-65%), particularly messages highlighting harms to human or animal life and welfare (all ≥60%). Across all message themes, younger adults (18-35 years) and those who completed tertiary education were more likely to perceive some messages as motivating. Perceived motivation did not vary significantly by gender, SES or geographical region. CONCLUSION: Findings suggest that value-based messaging featuring the environmental and social justice footprint of tobacco is perceived as motivating for smoking cessation, especially among younger people and those with higher education who may be more engaged with these issues. Inclusion of such messages as part of a comprehensive antitobacco communication strategy may provide an untapped opportunity by potentially providing people who smoke with additional compelling reasons to quit.

Impact of three annual tobacco tax rises on tobacco sales in remote Australian Aboriginal community stores.

BACKGROUND: There is strong evidence from many settings that tobacco tax rises which increase prices reduce tobacco consumption, but only limited evidence from Indigenous settings. METHODS: We analysed 3 years (2016-2018) of weekly sales data from 32 stores in remote Aboriginal communities. We used interrupted time series analysis to estimate the immediate impact of the price rice following annual 12.5% tobacco tax rises on sales on (A) stick equivalents of tobacco and (B) fruit and vegetables (kg) per $A1000 of grocery sales, and on the trend in sales between price rises. RESULTS: We detected 5.8% and 8.2% immediate declines in tobacco sales following the price rises associated with annual 12.5% tax rises in 2016 and 2018, and a non-significant decline (1.6%) following the 2017 tax rise. Decreased sales were mainly driven by declines in mainstream and premium factory-made cigarettes. Fruit and vegetable sales did not change at the time of tobacco price rises. CONCLUSION: For the first time, we demonstrated evidence of price-sensitivity and the immediate impact of price rises from tobacco tax rises on tobacco sales in remote Aboriginal communities. We acknowledge that Australia already has very high tobacco taxation and prices, but recommend further increases to the taxation of roll-your-own (RYO) tobacco to prevent smokers and industry using cheaper RYO cigarettes to undermine this impact of high tobacco taxes and prices.

Smoking prevalence following tobacco tax increases in Australia between 2001 and 2017: an interrupted time-series analysis.

BACKGROUND: Building on substantial tobacco control action over the previous decade, Australia increased the taxes on tobacco by 25% without forewarning on April 30, 2010. Australia then became one of a few countries to pre-announce a series of increases in tobacco taxes, with annual 12·5% increases starting from December, 2013. We aimed to examine the effects of both tax increases on smoking prevalence. METHODS: By use of survey data from Australians aged 14 years and older in five capital cities, we did an interrupted time-series analysis to model the monthly prevalence of smoking (overall, of factory-made cigarettes [FMC], and of roll-your-own tobacco [RYO]), in the total sample and stratified by socioeconomic status subgroups. We measured outcomes in May, 2001-April, 2010; May, 2010-November, 2013; and December, 2013-April, 2017. FINDINGS: The 25% tax increase was associated with immediate (-0·745 percentage points; 95% CI -1·378 to -0·112) and sustained reductions in prevalence (monthly trend -0·023 percentage points; -0·044 to -0·003), which were driven by reductions in the prevalence of smoking of FMC. The prevalence of smoking of RYO increased between May, 2010, and November, 2013, after the 25% tax increase. At the start of the pre-announced annual 12·5% increases, we observed an immediate reduction in smoking (-0·997 percentage points; -1·632 to -0·362), followed by decreasing overall prevalence (monthly trend -0·044 percentage points; -0·063 to -0·026) due to ongoing decreases in the prevalence of FMC smoking and a cessation of increases in the prevalence of smoking of RYO. Immediate decreases in smoking and changing trends in the prevalence of smoking of RYO were most evident among groups with a lower socioeconomic status. INTERPRETATION: Large tax increases are effective in reducing smoking prevalence, both as a single increase without forewarning and as a pre-announced series of increases. However, taxes on tobacco are best structured to apply equally to FMC and RYO products. Tobacco control policies should prohibit price marketing that otherwise erodes the full impact of such tax increases. FUNDING: Cancer Council Victoria.

Are Australians ready for warning labels, marketing bans and sugary drink taxes? Two cross-sectional surveys measuring support for policy responses to sugar-sweetened beverages.

OBJECTIVE: To assess public support for 10 potential policy initiatives to reduce sugar-sweetened beverage (SSB) consumption. DESIGN: A 2014 historical data set, which employed a face-to-face survey in one Australian state (study 1), provided the basis for comparison with our 2017 nationally representative, cross-sectional, computer-assisted telephone interviewing population survey (study 2). PARTICIPANTS: Study 1: South Australians, 15+ years (n=2732); study 2: Australians, 18+ years (n=3430). PRIMARY OUTCOME MEASURES: levels of support for SSB-specific policy initiatives. For the 2017 national study (study 2), demographic characteristics, body mass index, knowledge of potential harms caused by consuming SSBs and SSB consumption were included in multivariable regression analyses. RESULTS: In 2017, all 10 potential policy initiatives received majority support (60%-88% either 'somewhat' or 'strongly' in favour). Initiatives with educative elements or focused on children received high support (>70%), with highest support observed for text warning labels on drink containers (88%) and government campaigns warning of adverse health effects (87%). Higher support was observed for SSB tax paired with using funds for obesity prevention (77%) than a stand-alone tax (60%). Support for policy initiatives was generally greater among those who believed SSB daily consumption could cause health problems in adults (4%-18% absolute difference) and/or in children (8%-26% absolute difference) and lower among SSB high consumers (7+ drinks per week; 9%-29% absolute difference). State-specific data comparison indicated increased support from 2014 to 2017 for taxation (42%vs55%; χ2=15.7, p<0.001) and graphic health warnings (52%vs68%; χ2=23.4. p<0.001). CONCLUSIONS: There is strong public support for government action, particularly regulatory and educational interventions, to reduce SSB consumption, which appears to have increased since 2014. The findings suggest that framing policies as protecting children, presenting taxation of SSBs in conjunction with other obesity prevention initiatives and education focused on the harms associated with SSB consumption will increase support.

Impact of a mass media campaign on participation rates in a National Bowel Cancer Screening Program: a field experiment.

OBJECTIVES AND DESIGN: This field experiment aimed to compare bowel cancer screening participation rates prior to, during and after a mass media campaign promoting screening, and the extent to which a higher intensity campaign in one state led to higher screening rates compared with another state that received lower intensity campaign exposure. INTERVENTION: An 8-week television-led mass media campaign was launched in selected regions of Australia in mid-2014 to promote Australia's National Bowel Cancer Screening Program (NBCSP) that posts out immunochemical faecal occult blood test (iFOBT) kits to the homes of age-eligible people. The campaign used paid 30-second television advertising in the entire state of Queensland but not at all in Western Australia. Other supportive campaign elements had national exposure, including print, 4-minute television advertorials, digital and online advertising. OUTCOME MEASURES: Monthly kit return and invite data from NBCSP (January 2012 to December 2014). Return rates were determined as completed kits returned for analysis out of the number of people invited to do the iFOBT test in the current and past 3 months in each state. RESULTS: Analyses adjusted for seasonality and the influence of other national campaigns. The number of kits returned for analysis increased in Queensland (adjusted rate ratio 20%, 95% CI 1.06% to 1.35%, p<0.01) during the months of the campaign and up to 2 months after broadcast, but only showed a tendency to increase in Western Australia (adjusted rate ratio 11%, 95% CI 0.99% to 1.24%, p=0.087). CONCLUSIONS: The higher intensity 8-week television-led campaign in Queensland increased the rate of kits returned for analysis in Queensland, whereas there were marginal effects for the low intensity campaign elements in Western Australia. The low levels of participation in Australia's NBCSP could be increased by national mass media campaigns, especially those led by higher intensity paid television advertising.

Indexation of Tobacco Excise and Customs Duty and Smoking Prevalence Among Australian Adults, 2001-2010: A Serial Cross-sectional Study.

INTRODUCTION: Australia's excise and customs duty on tobacco has been automatically increased biannually since 1984. Increases in duty on par with inflation ensured that tobacco stayed at least as costly as other goods. This would be expected to maintain, rather than drive down, smoking prevalence. We examined the association between smoking prevalence and duty over a 10-year period. METHODS: Using monthly data from five Australian capital cities, collected from March 2001 to March 2010 among Australians aged at least 18 years, multiple linear regression modeled associations between smoking prevalence and the two components (duty and non-duty) of the recommended retail price of an average packet of cigarettes, adjusting for policy covariates. RESULTS: Prevalence declined from 23.6% in March 2001 to 17.0% in March 2010 [absolute difference 6.6%; 95% confidence interval (CI) = 6.5 to 6.8]. Duty increased from $0.2026 to $0.2622 per cigarette over the same period. In the adjusted model, a 1-cent increase in the duty component of price was not associated with changes in prevalence (0.019; 95% CI = -0.035 to 0.028). Increased non-duty component of price was associated with a decline in prevalence (-0.027; 95% CI = -0.052 to -0.002). This effect was stronger when changes in income were controlled for. CONCLUSIONS: In line with expectations, inflation-adjusted duty was not associated with changes in smoking prevalence, but it may have prevented upward pressure on prevalence that increasing affordability could have exerted. Frequent increases in duty greater than the growth in both wages and goods would more effectively reduce smoking than regular indexation. IMPLICATIONS: Few countries inflation-adjusted excise duty to ensure that tobacco products do not become more affordable; however, Australia experienced a decade of inflation adjustment alone, enabling the impact of this policy to be studied. This study shows that inflation-adjusted duty likely did prevent tobacco becoming more affordable and that indexation was associated with declines in smoking when tobacco companies over-shifted the duty rises (ie, increased price over and above duty rises).The study also suggests that frequent increases in taxation that exceed both wage growth and increases in costliness of other goods are needed to prompt increased rates of quitting.

Anti-smoking social norms are associated with increased cessation behaviours among lower and higher socioeconomic status smokers: A population-based cohort study.

BACKGROUND: Social denormalisation of smoking can provide an environment that helps smokers to quit. This study examined which of three measures of anti-smoking social norms have the greatest influence on quitting-related cognitions and behaviours, and if this influence differs according to socioeconomic status (SES). METHODS: The Victorian Tracking Survey measured social norms among 1,348 (n(weighted) = 1,373) Australian adult smokers (aged 18-59) between 2012 and 2014, who were followed-up one week later. Weighted logistic regression analyses examined prospective associations of baseline subjective (family and friends' disapproval of smoking), injunctive (feeling embarrassed about being a smoker) and descriptive norms (living with someone who tried to quit in the past 12 months), with quitting-related cognitions and behaviours at follow-up. Data were weighted to account for telephony status (landline or mobile phone), sex and age. Analyses were adjusted for demographic characteristics, addiction level, tobacco control policies and quitting-related outcomes measured at baseline. Differences in associations between lower and higher SES smokers (based on educational attainment and area-based disadvantage) were examined through interaction terms and stratified analyses. RESULTS: Sixty-four percent of participants (n(weighted) = 872) perceived disapproval from family and friends, 31% (n(weighted) = 419) felt embarrassed to be a smoker, and 11% (n(weighted) = 155) lived with a recent quitter. All three norms were associated with having set a firm date to quit in the next month and with engaging in smoking limiting behaviours. Embarrassment was also associated with an increased likelihood of talking about quitting and with making a quit attempt. Associations were mostly comparable for lower and higher SES smokers, with no significant negative rebound effects overall or among subgroups. CONCLUSIONS: These findings indicate close others' disapproval and feelings of embarrassment most strongly motivate smokers to try to quit. If tobacco control policies or media campaigns further denormalise smoking, there should be no reason for concern that such denormalisation undermines cessation behaviours.

Public awareness and misunderstanding about DrinkWise Australia: a cross-sectional survey of Australian adults.

OBJECTIVE: DrinkWise Australia is an alcohol industry Social Aspects/Public Relations Organisation (SAPRO). We assessed the Australian public's awareness of DrinkWise, beliefs about its funding source, and associations between funding beliefs and perceptions of DrinkWise. METHODS: A total of 467 adult weekly drinkers completed an online cross-sectional survey in February 2016. RESULTS: Half the sample had heard of DrinkWise (48.6%); of these, the proportion aware that DrinkWise is industry funded (37.0%) was much smaller than the proportion believing it receives government funding (84.1%). Respondents who incorrectly believed DrinkWise receives government funding were more likely to hold a favourable perception of the organisation's credibility, trustworthiness and respectability than those who did not believe it receives government funding (75.9% vs. 58.3%; p=0.032). CONCLUSIONS: The drinking population is vulnerable to believing that alcohol industry public relations organisations such as DrinkWise are government funded, which in turn is associated with more favourable perceptions of the organisation's credibility, trustworthiness, and respectability. Implications for public health: Favourable perceptions of DrinkWise may enhance the industry's ability to delay or dilute potentially effective alcohol control policies. Future research should investigate whether educating the public about DrinkWise's alcohol industry funding alters the public's perception of how credible, trustworthy and respectable the organisation is.

Time series analysis of the impact of tobacco control policies on smoking prevalence among Australian adults, 2001-2011.

OBJECTIVE: To determine the impact of tobacco control policies and mass media campaigns on smoking prevalence in Australian adults. METHODS: Data for calculating the average monthly prevalence of smoking between January 2001 and June 2011 were obtained via structured interviews of randomly sampled adults aged 18 years or older from Australia's five largest capital cities (monthly mean number of adults interviewed: 2375). The influence on smoking prevalence was estimated for increased tobacco taxes; strengthened smoke-free laws; increased monthly population exposure to televised tobacco control mass media campaigns and pharmaceutical company advertising for nicotine replacement therapy (NRT), using gross ratings points; monthly sales of NRT, bupropion and varenicline; and introduction of graphic health warnings on cigarette packs. Autoregressive integrated moving average (ARIMA) models were used to examine the influence of these interventions on smoking prevalence. FINDINGS: The mean smoking prevalence for the study period was 19.9% (standard deviation: 2.0%), with a drop from 23.6% (in January 2001) to 17.3% (in June 2011). The best-fitting model showed that stronger smoke-free laws, tobacco price increases and greater exposure to mass media campaigns independently explained 76% of the decrease in smoking prevalence from February 2002 to June 2011. CONCLUSION: Increased tobacco taxation, more comprehensive smoke-free laws and increased investment in mass media campaigns played a substantial role in reducing smoking prevalence among Australian adults between 2001 and 2011.

Making news: the appearance of tobacco control organizations in newspaper coverage of tobacco control issues.

PURPOSE: To characterize the presence of advocacy groups in media coverage about tobacco issues. DESIGN: A content analysis of tobacco-related newspaper articles. SETTING: Australia. SAMPLE: All 12 national and state capital daily newspapers published in Australia between 2004 and 2007. MEASURES: We coded each article for explicit mentions of any of 16 major national or state tobacco control advocacy groups; for the article type, prominence, and topic; for the tone of the event; and for the author's opinion. ANALYSIS: A series of 2 × 2 χ(2) analyses assessed the extent to which advocacy groups were more or less likely to be mentioned in articles of each type, prominence, topic, event impact, and opinion orientation. RESULTS: Of the 4387 tobacco-related articles published over this period, 22% mentioned an advocacy group. There was a greater-than-expected proportion of advocacy groups mentioned in news articles with very high prominence (44%; χ(2) [1, N = 3118] = 27.4, p < .001), high prominence (34%; χ(2) [1, N = 3118] = 10.9, p < .001), and medium prominence (30%; χ(2) [1, N = 3118] = 7.3, p = .007), and in articles covering events with mixed (30%; χ(2) [1, N = 4387] = 10.0, p = .002) or positive (24%; χ(2) [1, N = 4387] = 26.1, p < .001) implications for tobacco control. CONCLUSIONS: Australian tobacco control advocacy groups have a reasonable presence within the news discourse on tobacco control issues and so are likely to contribute to generating and shaping this discourse, particularly in relation to evolving and controversial issues.

Which types of televised anti-tobacco campaigns prompt more quitline calls from disadvantaged groups?

To examine the efficacy of different types of mass media ads in driving lower socio-economic smokers (SES) to utilize quitlines. This study collected all 33 719 calls to the Victorian quitline in Australia over a 2-year period. Negative binomial regressions examined the relationship between weekly levels of exposure to different types of anti-smoking ads and quitline calls, after adjusting for covariates. Interaction terms were added to determine whether relationships differed by SES. In total, smokers were exposed 88.39 times to anti-smoking ads over the 2-year period, as estimated by target audience ratings points. Higher emotion narrative ad exposure had the strongest association with quitline calls, increasing call rates by 13% for every additional ad exposure per week (per 100 points, rate ratio = 1.132, P = 0.001). Substantially, greater increases in calls to quitline from lower SES groups were observed when higher emotion narrative ads were on air compared with when other ad types were on air, and this advantage was not as strong among higher SES groups. Airing higher emotion narrative anti-smoking ads may contribute to reducing, but not eliminating, socio-economic disparities in calls to the quitline through maximizing the responses of the lower SES smokers.

Effects of different types of antismoking ads on reducing disparities in smoking cessation among socioeconomic subgroups.

OBJECTIVES: We assessed which types of mass media messages might reduce disparities in smoking prevalence among disadvantaged population subgroups. METHODS: We followed 1491 adult smokers over 24 months and related quitting status at follow-up to exposure to antismoking ads in the 2 years prior to the baseline assessment. RESULTS: On average, smokers were exposed to more than 200 antismoking ads during the 2-year period, as estimated by televised gross ratings points (GRPs). The odds of having quit at follow-up increased by 11% with each 10 additional potential ad exposures (per 1000 points, odds ratio [OR]=1.11; 95% confidence interval [CI]=1.00, 1.23; P<.05). Greater exposure to ads that contained highly emotional elements or personal stories drove this effect (OR=1.14; 95% CI 1.02, 1.29; P<.05), which was greater among respondents with low and mid-socioeconomic status than among high-socioeconomic status groups. CONCLUSIONS: Emotionally evocative ads and ads that contain personalized stories about the effects of smoking and quitting hold promise for efforts to promote smoking cessation and reduce socioeconomic disparities in smoking.

Taxation reduces social disparities in adult smoking prevalence.

BACKGROUND: The CDC, the WHO, and the World Bank promote increases in the price of cigarettes as an effective and important tobacco-control strategy. This study was designed to assess the extent to which the association between the price of cigarettes and smoking prevalence, as measured monthly, varies by income group. METHODS: Australian population survey data collected monthly from January 1991 to December 2006 were used to estimate Poisson regression models to assess the impact of the price of cigarettes on smoking prevalence across three income groups. Analyses were conducted in 2008. RESULTS: There was strong evidence that real price and prevalence were negatively associated (p<0.001) and that the association was stronger in lower-income groups (p<0.001). One Australian dollar increase in price was associated with a decline of 2.6%, 0.3%, and 0.2% in the prevalence of smoking among low-, medium-, and high-income groups, respectively. CONCLUSIONS: Increasing the price of cigarettes not only is an effective tobacco-control strategy to lower smoking prevalence in the general population, but also may provide a means of reducing social disparities in smoking.