Tobacco packaging littering behaviours among Australian adults who smoke: findings from cross-sectional and observational studies to inform the implementation of cigarette pack inserts.

BACKGROUND: Cigarette pack inserts are small cards that highlight the benefits of quitting and promote use of smoking cessation support. With evidence from Canada that they increase self-efficacy to quit, quit attempts and sustained cessation, inserts are set to be introduced into tobacco packs sold in Australia. Some people have expressed concern that the introduction of inserts may create more litter if incorrectly disposed of on pack-opening. METHODS: We used a cross-sectional survey to assess self-reported pack-opening location and waste disposal behaviours of people who smoke to determine the potential for littering to occur when tobacco packs are first opened. We also visited a sample of supermarkets, convenience stores and tobacconists located throughout Melbourne, Australia, to discreetly collect observational data regarding pack-opening and waste disposal behaviours at the point of purchase. RESULTS: Among participants in the cross-sectional study (N=369), the majority reported that they opened their most recent tobacco pack at home (70.9%) where there is little potential for littering, and this proportion was higher among those who smoke daily (78.6%) and men (74.3%). Self-reported behaviours that could result in littering were rare; 1.0% reported that they left tobacco packaging where they believed it would be collected for disposal. Of the 128 individuals observed at the point of purchase across 46 stores, 96.9% did not open the tobacco product immediately after purchase. One incident of littering was observed (0.8%). CONCLUSION: The introduction of cigarette pack inserts in Australia is unlikely to create a substantial amount of additional litter.

Tobacco purchasing in Australia during regular tax increases: findings from the International Tobacco Control Policy Evaluation Project.

OBJECTIVE: We examined Australian tobacco purchasing trends, the average self-reported price paid within each purchase type and the association between type of tobacco product purchased and participant characteristics, including quit intentions, between 2007 and 2020. METHODS: We analysed data collected from adults who smoked factory-made and/or roll-your-own (RYO) cigarettes in nine waves (2007-2020) of the International Tobacco Control Policy Evaluation Project Australia Survey (nsample=5452, nobservations=11 534). The main outcome measures were type of tobacco products purchased: RYO, carton, pack or pouch size and brand segment. Logistic regression, fit using generalised estimating equations, was estimated the association between the outcome and participant characteristics. RESULTS: The reported price-minimising purchasing patterns increased from 2007 to 2020: any RYO (23.8-43.9%), large-sized pack (2007: 24.0% to 2016: 34.3%); shifting from large-sized to small-sized packs (2020: 37.7%), and economy brand (2007: 37.2% to 2020: 59.3%); shifting from large (2007: 55.8%) to small economy packs (2014: 15.3% to 2020: 48.1%). Individuals with a lower income, a higher nicotine dependence level and no quit intention were more likely to purchase RYO and large-sized packs. CONCLUSION: RYO, large-sized packs and products with a low upfront cost (eg, small RYO pouches and small-sized economy brand packs) may appeal to people on low incomes. Australia's diverse tobacco pack and pouch sizes allow the tobacco industry to influence tobacco purchases. Standardising pack and pouch sizes may reduce some price-related marketing and especially benefit people who have a low income, are highly addicted and have no quit intention.

Fifty-year forecasts of daily smoking prevalence: can Australia reach 5% by 2030?

OBJECTIVE: To compare 50-year forecasts of Australian tobacco smoking rates in relation to trends in smoking initiation and cessation and in relation to a national target of ≤5% adult daily prevalence by 2030. METHODS: A compartmental model of Australian population daily smoking, calibrated to the observed smoking status of 229 523 participants aged 20-99 years in 26 surveys (1962-2016) by age, sex and birth year (1910-1996), estimated smoking prevalence to 2066 using Australian Bureau of Statistics 50-year population predictions. Prevalence forecasts were compared across scenarios in which smoking initiation and cessation trends from 2017 were continued, kept constant or reversed. RESULTS: At the end of the observation period in 2016, model-estimated daily smoking prevalence was 13.7% (90% equal-tailed interval (EI) 13.4%-14.0%). When smoking initiation and cessation rates were held constant, daily smoking prevalence reached 5.2% (90% EI 4.9%-5.5%) after 50 years, in 2066. When initiation and cessation rates continued their trajectory downwards and upwards, respectively, daily smoking prevalence reached 5% by 2039 (90% EI 2037-2041). The greatest progress towards the 5% goal came from eliminating initiation among younger cohorts, with the target met by 2037 (90% EI 2036-2038) in the most optimistic scenario. Conversely, if initiation and cessation rates reversed to 2007 levels, estimated prevalence was 9.1% (90% EI 8.8%-9.4%) in 2066. CONCLUSION: A 5% adult daily smoking prevalence target cannot be achieved by the year 2030 based on current trends. Urgent investment in concerted strategies that prevent smoking initiation and facilitate cessation is necessary to achieve 5% prevalence by 2030.

Where to next for countries with high tobacco taxes? The potential for greater control of tobacco pricing through licensing regulation.

Optimising the taxation of tobacco products should be among the highest priorities for health and hence economic policy in every country. The WHO Technical Manual on Tobacco Tax Policy and Administration released in April 2021 provides invaluable advice, including 26 best practice recommendations on policy design, administrative efficiency and addressing industry tactics to circumvent tobacco tax increases. Introducing and increasing tobacco taxes is the most important tobacco control measure for any jurisdiction. The effects of simple tax structures, high tax levels, and frequent above-inflation increases in specific excise duties can be enhanced through strict controls on packaging (including pack size), product design, and discounting. However, even with such measures, tobacco companies can continue to undermine the effectiveness of tax policy by offering some products in their ranges at very low prices, as well as gradually and selectively increasing the prices of some but not all products after tax increases. This paper is aimed at policymakers in countries that have already adopted best practice tax policy. It explores the idea of wholesale price capping combined with retail licensing to address the problems of brand proliferation, dispersion of prices, cushioning and strategic under/overshifting of tax increases, thereby radically and sustainably increasing the effectiveness of tobacco tax policy while also raising additional tax revenue for governments by reducing industry profitability.

Evidence of cushioning of tobacco tax increases in large retailers in Australia.

BACKGROUND: Tobacco companies may attempt to minimise the impact of tobacco tax increases on consumers by gradually passing on the price rise over several months. This study examined whether there was evidence of large Australian tobacco retailers engaging in this practice (known as cushioning) over a period including both routine indexation and large annual tobacco excise increases. METHODS: Advertised prices of nine factory-made cigarette (FMC) and nine roll-your-own tobacco (RYO) products were recorded from two stores monthly from December 2016 to December 2019. Per cent change in price from the previous month was analysed for FMC and RYO products, controlling for year, month, tobacco company and supermarket chain. RESULTS: Significant main effects of month were observed for FMC and RYO products (both p<0.001). Large, significant average increases in per cent change in price were observed in September for FMC (6.51%) and RYO (11.45%) products, the month of the annual excise increase and prices also significantly increased in October (FMC: 3.01%; RYO: 1.91%). Significant increases were also observed in the months after the March annual routine indexation: by 1.10% in May for FMC products and by 1.09% in April for RYO products. CONCLUSION: This study has demonstrated evidence of cushioning of tax increases of FMC and RYO products in large Australian supermarkets. The monthly per cent change in price significantly increased several months after routine excise indexation and in the 2 months following a large annual excise increase. Further research with a larger sample of products and stores is needed to confirm these findings.

Public support for policies to phase out the retail sale of cigarettes in Australia: results from a nationally representative survey.

BACKGROUND: There is growing international interest in a goal once considered unthinkable: phasing out the retail sales of smoked tobacco products. In this study, we examined public support for phasing out sales and specific measures for moving towards a phase-out among a nationally representative sample of Australian adults. METHODS: In December 2019, we used a probability-based online panel, Life in Australia™, to survey n=1939 Australian adults (n=1874 included in analyses due to missing data). RESULTS: Almost two-thirds of respondents thought it would be 'a good thing' if there came a time when it was no longer legal to sell cigarettes in shops in Australia and only 16.7% thought it would be 'a bad thing'. After the concept of a phase-out was defined as removing a product from the Australian market over a set period, such as 5 years, but still allowing purchases online from overseas companies, 50.7% indicated support for such a phase-out and 61.8% thought it should happen within 10 years. Support was greater for specific measures such as licensing tobacco retailers (75.3%) and restricting sales to places children cannot enter (76.3%). Support tended to be consistent across demographic subgroups but was stronger among never and former smokers than among current smokers. CONCLUSIONS: There has been little public discussion in Australia about the goal of 1 day phasing out the retail sale of cigarettes. It is notable that such policies are reasonably well supported by the Australian public, with only minority opposition.

Addressing lower-priced cigarette products through three-pronged comprehensive regulation on excise taxes, minimum price policies and restrictions on price promotions.

The prices that smokers pay out-of-pocket for their tobacco products ultimately influence their smoking behaviour. Although cigarette excise taxes are arguably the best and most used policy to increase cigarette prices, taxes are only one component of retail cigarette prices. The persistence of lower-priced products, disproportionately purchased by lower-income smokers, in jurisdictions with high excise taxes is an Achilles heel for tobacco tax policy. When governments raise excise taxes, the tobacco industry responds. The industry reduces tax pass-through to minimise the price increases for lower-priced brands and offers price discounts to retailers and coupons to consumers. In addition, smokers who do not quit after tax increases may downshift brands, purchase in bulk or substitute lower-priced tobacco product types. This may be particularly true for price-sensitive smokers, including those with lower incomes. We propose that raising excise taxes will be more effective in reducing the persistence of lower-priced products and income-based smoking disparities when taxes are designed to raise prices frequently and substantially for all products and are combined with (a) minimum price laws and (b) bans on coupons, discounts and other promotions. In combination, these three complementary policies restrict the tobacco industry's ability to undermine the impact of higher excise taxes upon consumer prices. Very few jurisdictions have implemented comprehensive three-pronged tobacco price regulation, but doing so would likely address many of the limitations that come with a sole focus on raising excise taxes.

Household expenditure of smokers and ex-smokers across socioeconomic groups: results from a large nationwide Australian longitudinal survey.

BACKGROUND: Countries with best practice tobacco control measures have experienced significant reductions in smoking prevalence, but socioeconomic inequalities remain. Spending on tobacco products, particularly by low-income groups can negatively affect expenditure on other goods and services. This study aims to compare the household expenditure of adults who smoke tobacco products and those who formerly smoked across socioeconomic groups. METHODS: Daily smokers and ex-smokers were compared using the Household, Income and Labour Dynamics in Australia Survey, over 7 waves. Adults who never smoked were not included. Participants were continuing sample members across waves. Mean number of participants per wave was 2505, 25% were smokers and 75% ex-smokers. The expenditure variables investigated included tobacco products, alcohol, motor vehicle fuel, health practitioners, insurance, education, and meals eaten out. Regression models using the generalized estimating equation technique were employed to compare expenditure data aggregated across the waves by Socioeconomic Index for Areas (SEIFA) quintiles of relative socio-economic advantage/disadvantage while accounting for within-participant autocorrelation. Quintiles are ranked by information such as the income, occupation and access to material and social resources of the residents. RESULTS: Smokers from all quintiles spent significantly less per year on meals out, education and insurance than ex-smokers (p < 0.001). Smokers from quintiles 2-5 spent less on groceries, medicines, and health practitioners (p < 0.01). Smokers from quintiles 1 and 2 (most disadvantaged), spent less on motor vehicle fuel than ex-smokers ($280;95%CI: $126-$434), ($213;95%CI: $82-$344). Smokers from quintiles 2 and 3 spent more on alcohol ($212;95%CI: $86-$339), ($231.8;95%CI: $94-$370) than ex-smokers. Smokers from the least disadvantaged groups spent less on clothing than ex-smokers ($348;95%CI: $476-$221), ($501; 95%CI: $743-$258). Across the whole sample, smokers spent more than ex-smokers on alcohol ($230;95%CI:$95-$365) and less on meals out ($361;95%CI:$216-$379), groceries ($529;95%CI:$277-$781), education ($456;95%CI:$288-$624), medicine ($71;95%CI:$38-$104), health practitioners ($345;95%CI:$245-$444) and insurance ($318;95%CI:$229-$407). CONCLUSIONS: Smoking cessation leads to reallocation of spending across all socioeconomic groups, which could have positive impacts on households and their local communities. Less spending on alcohol by ex-smokers across the whole sample could indicate a joint health improvement associated with smoking cessation.

Prevalence and correlates of flavour capsule cigarette use among Australian adolescents.

ISSUE ADDRESSED: Introduced relatively recently in the Australian market, flavour capsule cigarettes pose a risk to adolescents by providing a palatable pathway to smoking initiation. The present study aimed to establish the prevalence of the use of flavour capsule cigarettes in Australian adolescents and to examine the association between frequency of use and smoking behaviour and intentions and perceptions of cigarette brand differences. METHODS: Data were from a 2017 cross-sectional school-based survey of secondary students aged 12-17 years (N = 4266) in Victoria who self-reported their smoking behaviours, smoking intentions and cigarette brand perceptions. Regression analyses were conducted controlling for sex, age group, education sector and other covariates. RESULTS: Overall, 5% (n = 195) of all students reported ever using flavour capsule cigarettes. Of the 675 students who had ever smoked, 29% (n = 194) had tried a flavour capsule cigarette. The likelihood of past-month and past-week smoking was significantly higher, and future smoking intentions were significantly stronger, for ever-smokers who had used flavour capsule cigarettes multiple times compared to those who had never used this type of cigarette. Ever-smokers were more likely to agree that 'some brands of cigarettes are easier to smoke than others' if they had tried a flavour capsule cigarette. CONCLUSIONS: There are high levels of use of flavour capsule cigarettes among Australian adolescent smokers, with more frequent use associated with greater involvement in smoking. SO WHAT?: These findings add to those of other studies suggesting that flavour capsule cigarettes may have negative impacts on youth smoking, strengthening the case for their prohibition in Australia.

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.

Australian smokers' experiences and perceptions of recessed and firm filter cigarettes.

BACKGROUND: While cigarette filter modifications have long been used to increase product appeal and assuage health concerns, tighter marketing restrictions, including plain packaging, have further spurred the growth of filter variants. We explored and assessed experiences and perceptions of smokers who had tried and/or currently use recessed filter cigarettes (RFCs) and firm filter cigarettes (FFCs). METHOD: In November 2018, we undertook eight exploratory focus groups of Australian adult factory-made cigarette smokers (total n=56). In July 2019, we surveyed 999 smokers aged 18-69 years to quantify ever and current use of these products and associated beliefs and sensory experiences. RESULTS: Focus group and survey findings were consistent. Among 988 smokers who had at least tried factory-made cigarettes, 28.9% had tried FFCs and 11.1% currently smoked these, while 36.4% had tried RFCs and 7.5% currently smoked these. Smokers in both studies believed these filters may reduce harm and that FFCs increase appeal. In the survey, 58.9% of RFC triers agreed these hide the filter's brown stain and 48.9% agreed that RFCs keep harmful substances away from the mouth. Similarly, 58.4% of FFC triers agreed these trap more harmful substances than standard filters. Relative to standard filter cigarettes, more smokers experienced FFCs and RFCs as feeling clean (p=0.03) and more current FFC users experienced these as feeling smooth (p=0.01). CONCLUSION: RFCs and FFCs undermine plain packaging legislation, which aims to reduce appeal and minimise misperceptions about the relative harms of different tobacco products. Like other filter modifications, these filter variants should be disallowed.

Cigarette pack size and consumption: an adaptive randomised controlled trial.

BACKGROUND: Observational evidence suggests that cigarette pack size - the number of cigarettes in a single pack - is associated with consumption but experimental evidence of a causal relationship is lacking. The tobacco industry is introducing increasingly large packs, in the absence of maximum cigarette pack size regulation. In Australia, the minimum pack size is 20 but packs of up to 50 cigarettes are available. We aimed to estimate the impact on smoking of reducing cigarette pack sizes from ≥25 to 20 cigarettes per pack. METHOD: A two-stage adaptive parallel group RCT in which Australian smokers who usually purchase packs containing ≥25 cigarettes were randomised to use only packs containing either 20 (intervention) or their usual packs (control) for four weeks. The primary outcome, the average number of cigarettes smoked per day, was measured through collecting all finished cigarette packs, labelled with the number of cigarettes participants smoked. An interim sample size re-estimation was used to evaluate the possibility of detecting a meaningful difference in the primary outcome. RESULTS: The interim analysis, conducted when 124 participants had been randomised, suggested 1122 additional participants needed to be randomised for sufficient power to detect a meaningful effect. This exceeded pre-specified criteria for feasible recruitment, and data collection was terminated accordingly. Analysis of complete data (n = 79) indicated that the mean cigarettes smoked per day was 15.9 (SD = 8.5) in the intervention arm and 16.8 (SD = 6.7) among controls (difference - 0.9: 95%CI = - 4.3, 2.6). CONCLUSION: It remains unclear whether reducing cigarette pack sizes from ≥25 to 20 cigarettes reduces cigarette consumption. Importantly, the results of this study provide no evidence that capping cigarette pack sizes would be ineffective at reducing smoking. The limitations identified in this study can inform a more efficient RCT, which is urgently required to address the dearth of experimental evidence on the impact of large cigarette pack sizes on smoking. TRIAL REGISTRATION: https://doi.org/10.1186/ISRCTN34202533.

Tobacco Cost of Illness Studies: A Systematic Review.

INTRODUCTION: To identify studies reporting costs arising from tobacco use and detail their (1) economic approaches, (2) health outcomes, and (3) other cost areas included. METHODS: We searched PubMed, Scopus, Cochrane Library, EconLit, and Google Scholar for studies published between 2008 and April 2018 in English. Eligible articles reported tobacco-related costs and included all tobacco-using populations (multinational, national, subpopulations, and involuntary smokers). All economic approaches that resulted in monetary outcomes were included. We reported USD or converted local currencies to USD. Two health economists extracted and two researchers independently reviewed the data. RESULTS: From 4083 articles, we reviewed 361 abstracts and examined 79 full-texts, with 63 (1.6%) deemed eligible. There were three multinational, thirty-four national, twenty-one subpopulation or condition(s)-specific analyses, and five evaluating involuntary smoking. The diverse approaches and outcomes precluded integrating costs, but these were substantial in all studies. For instance, about USD 1436 billion in global health expenditures and productivity losses in 2012 and USD 9 billion in lost productivity in China, Brazil, and South Africa in 2012. At the national level, costs ranged from USD 4665 in annual per respondent health expenses (Germany 2006-2008) to USD 289-332.5 billion in medical expenses (United States 1964-2014). CONCLUSIONS: Despite wide variations in the methods used, the identified costs of tobacco are substantial. Studies on tobacco cost-of-illness use diverse methods and hence produce data that are not readily comparable across populations, time, and studies, precluding a consistent evidence-base for action and measurement of progress. Recommendations are made to improve comparability. IMPLICATIONS: In addition to the health and financial costs to individual smokers, smoking imposes costs on the broader community. Production of comparable estimates of the societal cost of tobacco use is impaired by a plethora of economic models and inconsistently included costs and conditions. These inconsistencies also cause difficulties in comparing relative impacts caused by differing factors. The review systematically documents the post-2007 literature on tobacco cost-of-illness estimations and details conditions and costs included. We hope this will encourage replication of models across settings to provide more consistent data, able to be integrated across populations, over time, and across risk factors.

Who sells tobacco, who stops? A comparison across different tobacco retailing schemes.

BACKGROUND: Licensing of tobacco retailers has been proposed as a mechanism to encourage retailers to stop selling tobacco. However, previous studies of tobacco licensing and/or of retailers who have stopped selling have been restricted to one legislative environment. This study examines patterns of tobacco retailing across three legislative environments with three different licensing schemes (an annual fee-based licence, a zero-cost, one-off notification scheme and no notification/licensing scheme). METHOD: A telephone survey was conducted of 2928 potential tobacco retailers who could personally choose whether or not to sell tobacco (rather than the decision being made at a head office). RESULTS: Unexpectedly, the annual licence fee to sell tobacco was not significantly associated with a lower rate of selling tobacco or a higher rate of stopping. After allowing for other factors, probability of selling, stopping selling and reported importance of tobacco sales varied across outlet types (p<0.001 for all three outcomes), and according to the remoteness of the retailer (p<0.001, p trend=0.041 and p=0.025 respectively). CONCLUSION: A fee of $A286 was not associated with a lower rate of selling, or a higher rate of stopping. The effect of licensing on retailer numbers will presumably be greater for higher licence fees, but will also depend on the perceived importance of tobacco sales to the retailer. In turn, importance of tobacco sales appears to depend on market factors, including proximity to major urban centres and low-cost competitors. A higher licence fee is likely to have a larger effect on discouraging retailers from selling.

'Friends with benefits': how tobacco companies influence sales through the provision of incentives and benefits to retailers.

BACKGROUND: In countries banning advertising and display of tobacco at point-of-sale, little is known about tobacco companies' continuing promotion of products through incentives and benefits to retailers. METHOD: A telephone survey of 4527 randomly selected Australian retailers was conducted in August 2018, and identified 800 current tobacco retailers (response rate: 72.4%) who were asked a series of questions about benefits offered to them by tobacco companies and what retailers agreed to in return. RESULTS: 41.1% of retailers reported being provided with a tobacco cabinet and 38.3% reported having a price list supplied by a tobacco company. One-third (33.3%) reported being offered at least one benefit from a tobacco company for doing something in return. Price discounts were the most frequently reported benefit (19.0%), followed by rebates (8.4%) and gifts (3.0%). Retailers also reported offers of prizes and incentives for increasing sales or demonstrating product knowledge. In return, retailers reported giving companies benefits such as prominence on the price list and/or in the tobacco cabinet and/or influence over the product range and stock levels. CONCLUSION: Tobacco companies are continuing to market tobacco and influence sales through provision of incentives and benefits to retailers. Laws that ban the supply of benefits to consumers should be extended to also prohibit the provision of benefits to tobacco retailers.

Understanding why some Australian retailers have stopped selling tobacco, some might and some are unlikely.

BACKGROUND: Widespread availability of tobacco has been shown to contribute to ongoing smoking and make quitting harder. This study investigates why some retailers in three Australian states decided to stop selling tobacco, others might stop selling and why others continue to sell in a declining market. METHODS: A telephone survey of 4527 randomly selected retailers was conducted in August 2018 (response rate=72.4%). This study examines responses to open-ended questions in the survey probing retailers' attitudes and beliefs regarding selling (or not selling) tobacco. RESULTS: 27.3% of the sample sold tobacco, and 13.3% had formerly sold. Outlets that had stopped selling most frequently mentioned minimal profit and/or sales as the reason for stopping selling (27.7% across all states). This was also the most frequent reason why retailers said they might stop selling. Uniquely in Western Australia (the only state in the study with a fee-based licensing scheme), 12.5% of former tobacco retailers named tobacco licensing as the reason for stopping sales-the second most frequent reason in Western Australia. Of current sellers who were unlikely to stop, the potential to lose sales was the most frequently named reason (31.0% across all states). CONCLUSION: Retailers report being driven by the profitability of tobacco when deciding whether or not to stop selling, although only a small percentage discussed losing incremental sales if they stopped selling. An annual licence fee contributed to some retailers stopping selling, showing that a fee-based tobacco license can contribute to a decline in retail availability of tobacco.

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.

Who uses rollies? Trends in product offerings, price and use of roll-your-own tobacco in Australia.

OBJECTIVE: We examined the roll-your-own (RYO) tobacco product market in Australia from 2001 to 2016. Trends in use of RYO tobacco among Australian adults were examined for 2004-2016. METHODS: Changes in brand availability, pouch sizes and lowest priced products were noted from trade magazines. Prevalence of smoking of RYO and factory-made (FM) cigarettes among those 18 years and older was obtained from five consecutive waves of a large (n>21 000) nationally representative triennial survey from 2004 to 2016. Trends in cigarette use were examined using logistic regression. RESULTS: Changes in the Australian RYO market from 2001 to 2016 included a doubling in the number of brands, progressively smaller pouch sizes with smaller increases in price than in traditional RYO and comparable FM products. While use of FM cigarettes declined between 2004 and 2016, the proportion of adults exclusively using RYO tobacco linearly increased with each survey wave (OR 1.03, 95% CI 1.02 to 1.05, p<0.001), from 1.2% in 2004 to 1.7% in 2016. Exclusive RYO use among current smokers increased more among females than males, and young adults compared with those aged 30 years or older, but did not differ by socioeconomic status. CONCLUSIONS: In contrast to substantial declines in FM cigarette use, exclusive use of RYO cigarettes increased in Australians since 2004, particularly among females and young adults. This has corresponded to a period of substantial changes to the RYO market, including progressively smaller and relatively more affordable products. Policy action to reduce price-related marketing and correct consumer misinformation about RYO tobacco are urgently required.

Hardening or softening? An observational study of changes to the prevalence of hardening indicators in Victoria, Australia, 2001-2016.

BACKGROUND: The hardening hypothesis predicts that as smoking prevalence declines, remaining smokers will be more heavily addicted to nicotine and/or less interested in quitting. We tested this hypothesis in a population exposed to a comprehensive tobacco control programme over a 16-year period. METHODS: Annual cross-sectional surveys randomly sampled adults (aged 26+) in the state of Victoria, Australia, between 2001 and 2016. Until 2010, participants were recruited through random digit dialling to landline telephones; from 2011, sampling frames also included mobile phones. Logistic regressions assessed changes over time in the prevalence of smoking and each hardening indicator; additional models examined interactions by sex, age, education and socioeconomic status. RESULTS: Smoking prevalence declined significantly between 2001 and 2016 (20.1%-13.0%), as did the prevalence of seven hardening indicators: daily smoking, heavy consumption, no quit attempt in the past 5 years or past 12 months, no intention to quit in the next 6 months or next 30 days, and happiness to keep smoking. In addition, the proportion of smokers defined as 'hardcore' decreased from 17.2% to 9.1%. On the whole, hardening indicators decreased to a similar extent among demographic subgroups. CONCLUSIONS: These results are inconsistent with the hardening hypothesis. Rather, they suggest that a comprehensive tobacco control programme that combines provision of cessation support to individual smokers with implementation of population-level interventions to drive all smokers towards quitting, can successfully reduce both smoking prevalence and levels of dependence and desire to keep smoking among the remaining population of smokers.

Tobacco product developments in the Australian market in the 4 years following plain packaging.

This paper aimed to identify continued and emerging trends in the Australian tobacco market following plain packaging implementation, over a period of substantial increases in tobacco taxes. Since 2012, our surveillance activities (including review of trade product and price lists, ingredient reports submitted by tobacco companies to government and monitoring of the retail environment) found several trends in the factory-made cigarette market. These include the continued release of extra-long and slim cigarettes and packs with bonus cigarettes, particularly in the mainstream and premium market segments; new menthol capsule products; other novel flavourings in cigarettes; filter innovations including recessed and firm filters; continued use of evocative and descriptive product names; the proliferation of the new super-value market segment; and umbrella branding, where new products are introduced within established brand families. Several similar trends were also observed within the smoking tobacco market. While not all of these trends were new to the Australian market at the time of plain packaging implementation, their continued and increased use is notable. Plain packaging legislation could be strengthened to standardise cigarette and pack size, restrict brand and variant names, and ban features such as menthol capsules and filters innovations that provide novelty value or that may provide false reassurance to smokers.