The impact of tobacco tax increases on cost-minimising behaviours and subsequent smoking cessation in Australia: an analysis of the International Tobacco Control Policy Evaluation Project.

OBJECTIVE: We examined the relationship in Australia from 2007 to 2020 between tobacco tax increases and use of cost-minimising behaviours (CMBs) when purchasing tobacco and: (1) tobacco expenditure and (2) smoking cessation attempts and quit success. METHODS: We used 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=4975, Nobservations=10 474). CMBs included buying RYO tobacco, cartons, large-sized packs, economy packs, or tax avoidance/evasion, smoking reduction and e-cigarette use. Logistic regression, fit using generalised estimating equations, estimated the CMB-outcome association for quit attempts and quit success at the next wave follow-up (Nsubsample=2984, Nobservations=6843). RESULTS: Over half of respondents used a CMB for tobacco purchase (P-CMB) at baseline (57.1% in 2007-2008), increasing to 76.8% (2018) post-tax increases. Participating in any P-CMB was associated with having higher weekly tobacco expenditure. Engaging in any P-CMB was negatively associated with attempting to quit (aOR=0.82, 95% CI 0.69-0.98). Purchasing RYO tobacco or cartons was associated with making no quit attempts (aOR=0.66, 95% CI 0.52-0.83; aOR=0.72, 95% CI 0.59-0.89, respectively). Among respondents smoking cigarettes who made quit attempts, there were no significant associations between all P-CMBs and quit success. Neither smoking reduction nor vaping were significantly associated with quit attempts. CONCLUSION: P-CMBs are associated with reduced smoking cessation. Reducing opportunities for industry to promote purchasing-related CMB options, such as by standardising pack sizes and reducing the price differential between RYO and manufactured cigarettes could increase the effectiveness of tax increases.

A systematic review of the modelling and economic evaluation studies assessing regulatory options for e-cigarette use.

BACKGROUND: Governments around the world are considering regulating access to nicotine e-cigarettes to prevent uptake among youth however people that smoke tobacco may use them to assist with smoking cessation. The health and cost implications of regulating e-cigarette use among populations are unknown but have been explored in modelling studies. We reviewed health economic evaluation and simulation modelling studies that assessed long-term consequences and interpret their potential usefulness for decision-makers. METHODS: A systematic review with a narrative synthesis was undertaken. Six databases were searched for modelling studies evaluating population-level e-cigarette control policies or interventions restricting e-cigarette use versus more liberalized use. Studies were required to report the outcomes of life years, quality-adjusted life years (QALYs) and/or healthcare costs. The quality of the studies was assessed using two quality assessment tools. RESULTS: In total, 15 studies were included with nine for the United States and one each for the United Kingdom, Italy, Australia, Singapore, Canada, and New Zealand. Three studies included cost-utility analyses. Most studies involved health state transition (or Markov) closed cohort models. Many studies had limitations with their model structures, data input quality and transparency, and insufficient analyses handling model uncertainty. Findings were mixed with 11 studies concluding that policies permitting e-cigarette use lead to net benefits and 4 studies concluding net losses in life-years or QALYs and/or healthcare costs.Five studies had industry conflicts of interest. CONCLUSIONS: While authors did conclude net benefit than net harm in more of the studies so far conducted, the significant limitations that we identified with many of the studies in this review, make it uncertain whether or not countries can expect net population harms or benefits of restrictive versus unrestrictive e-cigarette policies. The generalizability of the findings is limited for decision-makers. In light of the deep uncertainty around the health and economic outcomes of e-cigarettes, simulation modelling methods and uncertainty analyses should be strengthened.

A prescription model for vapes: the way we 'do' medicines policy in Australia.

On 2 May 2023, the Australian Federal Government announced a suite of reforms aimed at ensuring the effectiveness of the prescription model of regulation of vaping (or e-cigarette) products in Australia. These reforms are intended to protect Australians, particularly young people, from the harms of vaping and nicotine dependence. The ensuing public debate on the issue has often created the impression that the options under consideration are to either retain 'recently introduced' prescription regulation or to 'revert to' a retail supply approach. However, the sale of nicotine vapes by retailers such as tobacconists and convenience stores has never been lawful in Australia. The reforms do not seek to change the way nicotine vaping products are regulated, but rather to ensure that the existing prescription model can be effectively enforced and can function as originally intended. This paper describes the historical context and rationale for strengthening prescription regulation of vapes in this country.

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.

Cost-effectiveness and productivity impacts of call-back telephone counselling for smoking cessation.

OBJECTIVES: Few existing economic evaluations of telephone call-back services for smoking cessation (quitlines) include productivity measures. The Economics of Cancer Collaboration Tobacco Control (ECCTC) model was developed by adopting a societal perspective, including productivity impacts. STUDY TYPE: Economic simulation modelling Methods: A multi-health state Markov cohort microsimulation model was constructed. The population was the Victorian smoking population in 2018. The effectiveness of the Victorian Quitline was informed by an evaluation and compared with no service. Risks of developing disease for smokers and former smokers were obtained from the literature. The model calculated economic measures, including average and total costs and health effects; incremental cost-effectiveness ratios; and net monetary benefit (NMB) for both the healthcare and societal perspective. An extensive uncertainty analysis was conducted. RESULTS: The Quitline service is cost-effective and dominant from both healthcare and societal perspectives, reducing costs with greater health benefits compared with no service. The expected incremental NMB was $2912 per person from the healthcare perspective and $7398 from the societal perspective. Total cost savings were $869 035 of healthcare costs, $1.1 million for absenteeism, $21.8 million for lost workforce participation, and $8.4 million for premature mortality, with a total reduction in societal costs of $32.2 million, over the 80 year timeframe of the model. Probabilistic sensitivity analysis suggested a high degree of certainty in these results, and overall conclusions were robust to one-way sensitivity and scenario analyses. CONCLUSIONS: The Victorian Quitline service is cost-effective and should be retained and expanded where possible. The ECCTC model can be adapted to analyse the cost-effectiveness of other tobacco cessation interventions, populations and contexts.

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.

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.

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.

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.

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.

Monitoring changes in smoking and quitting behaviours among Australians with and without mental illness over 15 years.

OBJECTIVE: This study examines smoking prevalence and quitting behaviours among Australians with and without mental illness. METHODS: Analysis of data from Australia's triennial National Drug Strategy Household Surveys 2004-2019. The prevalence of regular smokers, never smokers, the quit proportion, cigarette consumption, and use of cessation aids were examined for those with and without mental illness. RESULTS: Among Australians with mental illness, there was a significant decrease in regular smokers and significant increases in never smokers and in the proportion of ever smokers who had quit between 2004 and 2019. Smokers with mental illness were generally as likely to attempt to quit and more likely to use cessation support; however, they were also more likely to report unsuccessful quit attempts. Smokers with mental illness who had quit reported lower levels of psychological distress than those still smoking. CONCLUSION: Since 2004, there have been some encouraging trends in reducing tobacco use among people with mental illness; however, smoking rates remain substantially higher than among those without mental illness. IMPLICATIONS FOR PUBLIC HEALTH: Findings highlight the importance of routinely identifying smokers with mental illness and improving access and adherence to best practice smoking cessation treatment.

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.

What is the likely impact on surgical site infections in Australian hospitals if smoking rates are reduced? A cost analysis.

INTRODUCTION: Assisting smokers to quit before surgery reduces surgical site infection (SSI) risk. The short-term economic benefits of reducing SSIs by embedding tobacco dependence treatment in Australian hospitals are unknown. Estimated annual number of SSIs prevented, and hospital bed-days (HBD) and costs saved from reducing smoking before surgery are calculated. METHODS: The most recent number of surgical procedures and SSI rates for Australia were sourced. The number of smokers and non-smokers having a SSI were calculated using the UK Royal College of Physicians reported adjusted odds ratio (1.79), and the proportion of SSIs attributable to smoking calculated. The potential impact fraction was used to estimate reductions in SSIs and associated HBDs and costs from reducing the smoking rates among surgical patients from 23.9% to 10% or 5% targets. Uncertainty around the final estimates was calculated using probabilistic sensitivity analysis. RESULTS: In 2016-17, approximately 40,593 (95% UI 32,543, 50,239) people having a surgical procedure in Australia experienced a SSI leading to 101,888 extra days (95% UI 49,988, 200,822) in hospital. If the smoking rate among surgical patients was reduced to 10%, 3,580 (95% UI 2,312, 5,178) SSIs would be prevented, and 8,985 (95% UI 4,094, 19,153) HBDs and $19.1M (95% UI $7.7M, $42.5M) saved in one year. If the smoking rate was reduced to 5%, 4,867 (95% UI 3,268, 6,867) SSIs would be prevented, and 12,217 (95% UI 5,614, 25,642) HBDs and $26.0M (95% UI $10.8M, $57.0M) would be saved. CONCLUSIONS: The findings suggest achieving smoking rate targets of 10% or 5% would provide substantial short-term health and economic benefits through reductions in SSIs. Embedding tobacco dependence treatment in Australian hospitals would provide value for money by reducing costs and improving clinical quality and safety. A more comprehensive, modelled economic evaluation synthesising the best available evidence is needed to confirm findings.

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.

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.

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.