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What is special about Australia? Sporting teams that usually win, poisonous snakes, and aggressive crocodiles all come to mind. But the country is also a world leader in tobacco control, as signified by the picture on the front cover. The detached eye was one of the iconic images used in a national tobacco control campaign notable for its media emphasis, the range of agencies involved, and the attention to evaluation. This supplement presents an account of the campaign.
To outsiders it sometimes comes as a surprise that Australia is such a loosely bound federation, with a history of differential tariffs, non-converging railway gauges (in the not so distant past), and separate codes of football (still). The States have considerable powers, are responsible for delivery of most health and social services, and for most of the 20th century undertook tobacco control. But it became clear that the scale of the problem demanded a broader view, and in 1996 the Federal government announced there would, for the first time, be a national tobacco control campaign. This would be a collaborative effort (including State and Federal governments and non-governmental organisations such as the Cancer Council), with an emphasis on cessation and the use of the mass media, and would aim to engage principally with young adult smokers (in the 18–40 year age range).1
The campaign was distinctive in many ways. For one, it took a new slant to anti tobacco advertising.2 The designers of the campaign concluded that challenging and memorable images of the harm done by smoking could be made relevant and empowering for smokers who had an intention to quit. This marked a move away from focusing on disease risk, to highlighting the immediate harmful consequences of tobacco. The argument was that these effects would be more difficult to pass off as “not relevant to me personally”, even if they were not as severe as conditions such as lung cancer and heart disease, which may be more common among smokers but do not affect everyone. From this decision came the motto of the campaign—“Every cigarette is doing you damage”.
Other features of the campaign included strong links between advertising and quit services, and substantial investments in these services to ensure they could accommodate the increased demands. The campaign was delivered in a phased manner, with new images and messages introduced in the second and third years. Evaluation was incorporated, tapping into a variety of process and outcome measures.
There is no doubt that the campaign was memorable. The images used in the first phase of the campaign (“lung”, “aorta”, and “tar”) were widely recognised, and stimulated demand for advice and support for cessation. Recall and recognition were closely related to intensity of campaign activities.3 Calls to Quitlines around Australia increased following advertising, but the relation between the two was not constant. It is interesting to note that there were no signs of smoker fatigue—indeed there were higher call rates per unit of advertising activity in later phases of the campaign.4
Did the campaign make a difference to smoking rates, overall? For the wealth of evaluation data that are available (and Australia is well served by long running smoking surveys), it is difficult to answer this question. For a start, it may be too soon to tell, with confidence, whether the long term trend in smoking prevalence has taken a new downward turn. The proportion of the adult Australian population who are regular smokers fell from 35% in the early 1980s to about 26% by the early 1990s. Progress then seemed to have stalled, with little change between 1992 and 1998. However, survey data for 2001 suggest that smoking rates may be coming down again (to 25% for men, 21% for women).5 These are positive signs, but can they be attributed to the campaign? In the same period there were other important things happening in tobacco control in Australia. For instance, between May 1997 and November 2000 the price of cigarettes rose by 25%.6 There were changes also in the range of cigarette brands on the Australian market, the extent of mandated smoke free environments, large scale advertising of nicotine replacement therapy by two pharmaceutical companies, and the promotion activities of the tobacco industry. It is a challenge to tease out the effects of any one of these variables, but there are favourable indications that the campaign helped many smokers in the direction of cessation. For example, there is strong evidence that the intensity of the campaign was associated with improvements in knowledge of the health consequences of smoking,7 increased intentions to stop smoking,7 and positive actions likely to lead to less smoking, such as calling the Quitline.3
Did the campaign influence social inequalities in smoking? Attempts were made to tailor the campaign to reach lower socioeconomic groups and non-English speaking Australians. These included deliberate placement of advertising in appropriate TV, radio, and print media, and choice of images and messages that were likely to resonate with specific groups. The evaluations suggest these tactics worked, at least in terms of recall of the campaign.7 It is more difficult to discern impacts on socioeconomic differences in smoking, but we note the picture in the longer term is one of increasing inequalities. Between 1980 and 2001 the reduction in smoking occurred more rapidly in white collar workers than blue collar workers. The gap in absolute terms remained about 20% (highest v lowest), but the relative difference increased from two- to threefold.5 In this respect, the trends in Australia resemble those in the USA8 and in the UK,9 where the socioeconomic gaps in smoking prevalence have also been widening.
Reducing smoking among deprived populations is particularly challenging due to at least three sets of constraints: firstly, because communicating knowledge about the hazards of smoking is insufficient for translation into action. Secondly, persistent smoking among disadvantaged groups may represent a rational response to their living conditions.9 That is, there is a mismatch between the hazards of smoking (which occur in the long term) and the pleasure of smoking in the short run, as well as the more immediate threats to life associated with dangerous jobs, unsafe neighbourhoods, and so on. Finally, we are dealing with an active and intelligent adversary, in the form of cigarette manufacturers who must maintain sales and profits in the face of disappearing consumption among the well educated and the affluent. Some have expressed skepticism about the ability of targeted initiatives to drive down the smoking prevalence in disadvantaged groups.9–10 However, the relevant counter-factual in Australia is whether the socioeconomic gaps would have been even greater in the absence of programmes tailored to the most vulnerable groups.
The largest inequalities in health in Australia are those between indigenous and non-indigenous peoples. In this supplement Briggs et al11 review what is currently known about tobacco and the health of Aboriginal and Torres Strait Islander Australians. The data are sparse, but indicate the prevalence of smoking is at least twice the average for the population as a whole, and few Aboriginal and Torres Strait Islander Australians report themselves to be ex-smokers. Very little is known about what tobacco control programmes work well with these communities but it is evident that what works for the majority of the population is not necessarily the solution for indigenous Australians. Briggs et al argue for better information, stronger community involvement, and an appreciation of the paramount importance of the social context of tobacco use.
What lessons might other countries draw from the Australian campaign? The importance of alliances would be one key message. This matters not just for credibility, but for the very practical reason that national campaigns are expensive and the costs are widely distributed. The close relation between advertising activity and phone calls to quitlines is a case in point. The Australian campaign was sustained because of its broad base, drawing together Federal and State governments, non-governmental organisations such as the Cancer Council, and service providers (for example Quitline). In this way it was possible to coordinate media activity and to make the links with cessation services (and fund these to accommodate demand). The campaign is also a testament to the power of images. Pictures like that on the front cover have imprinted themselves on the consciousness of Australians, and are now appearing in campaigns in many other countries. They tell only part of the story, but the longest lasting reminders of the Australian contribution to tobacco control will likely be “aorta”, “tar”, “lung”, and “eye”.
What about the future of tobacco control in Australia? Here the picture is not so rosy, as there is a serious risk that the momentum generated by the National Tobacco Campaign (NTC) will be lost. Funding for tobacco harm minimisation has not been sustained at NTC levels—the amount committed in the 1999–2002 triennium was one third that provided in the previous 3 years.12 With the exception of smoke free environments, there is a sense that tobacco control in Australia may be stalling again. The papers in this supplement tell a remarkable story. They demonstrate that national campaigns are effective in changing attitudes and readiness to quit, and that these are cost effective investments compared with dollars allocated to most other health programmes. It would be a tragedy if governments and others in the driving seat thought the NTC was over and done with, and now took their feet off the tobacco control pedal.