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Abstract
Background The tobacco-free generation (TFG) proposal advocates prohibiting the sale of tobacco products to people born after the year 2000. In a world-first, the Tasmanian parliament is considering this proposed legislation. Levels of public support for the proposal among adults and adolescents were investigated.
Methods Data were collected via 2 cross-sectional studies in 2014. 1 was a telephone survey of 600 randomly sampled Tasmanians aged 18 years or over, the other a pencil and paper survey of 1888 Tasmanian secondary school students aged 12–17 years.
Regression models were used to examine characteristics associated with support for adults and adolescents, weighted to account for sampling and the Tasmanian population.
Results Support for the TFG proposal was 75% among Tasmanian adults. Majority support extends across all sociodemographic subgroups, including 72% of current smokers. Support was higher among females and those educated up to year 12. Of those aged 12–17 years, 68% supported the TFG proposal, including 64% of those born after the year 2000, who would be directly affected by the TFG proposal. Support was higher among non-smokers and those born before the year 2000.
Conclusions/implications There is strong public support for the TFG proposal in Tasmania, even among smokers and people born after the year 2000.
- End game
- Prevention
- Public policy
- Public opinion
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Introduction
Tobacco is a highly addictive substance,1 causing death in up to two-thirds of long-term smokers.2 To realise a tobacco-free society, tobacco control advocates have been proposing ‘endgame’ strategies, which would allow a future without the widespread use and sale of tobacco products.3 ,4
The tobacco-free generation (TFG) proposal is one such endgame strategy.5 It proposes phasing in a ban on the sale of tobacco products to people born in or after, a specified year such as the year 2000. The TFG proposal has been analysed with reference to four international human rights documents,6 including the Universal Declaration of Human Rights.7 They concluded that the TFG proposal is compatible with human rights principles and the main obstacles to implementation are in achieving public support and compliance with the resulting legislation.6
Tasmania is a small island state in Australia with the second highest smoking prevalence in the country (19% compared to 16.0% nationally).8 A member of the Legislative Council (Tasmanian Upper House) tabled a private member's Bill9 in 2014 proposing an amendment to the Public Health Act to include the TFG. The study aimed to assess levels of support for the TFG proposal in Tasmania among adult and adolescent populations.
Methods
Two surveys assessed support for the TFG proposal: the Tasmanian Smoking and Health Survey (TSHS) and the Australian Secondary Students' Alcohol and Drug Survey (ASSAD).
The TSHS was conducted from November to December 2014 by random digit dialling to household telephones (n=600) and the response rate was 62%. From November 2014 to November 2015, 67% of Tasmanian households had a fixed-line telephone.10 Where a postal address was matched to the telephone number, an introductory letter was sent to notify households of the survey. Up to nine call attempts were made to complete an interview. Interviewers asked to speak with the youngest English-speaking male aged 18 years or over. If no males were available, the youngest English-speaking adult female was invited to take part. This was to increase responses among males and young people, who were anticipated to be under-represented. The survey was stratified by region with regional quotas in place. Verbal consent was obtained before proceeding with the interview. The survey asks about tobacco issues, including a question on the TFG proposal, modified from a previous study in Singapore:5 ‘Would you support a proposal that bans the sale of tobacco to Tasmanians born after the year 2000?’ (Responses of ‘yes’, ‘no’ or ‘don't know’ were received). As ‘don't know’ was only reported by 3% of respondents, these responses were excluded from analysis.
A two-stage weighting procedure was applied: (1) relative chance of inclusion based on the number of landline phone numbers and in-scope persons in a household and (2) population characteristics to obtain a representative sample.11
ASSAD, a survey of a random sample of secondary school students aged 12–17 years, was conducted from June to December 2014. A two-stage probability sampling method sampled schools, then students within schools, stratified by educational sector (Independent, Catholic and Government). Schools with fewer than 100 enrolments were excluded and 26 schools participated in the survey (41% response proportion). Parents provided informed passive consent. The aim was to survey 80 students from each school. Intact non-streamed and non-elective classes were randomly chosen within required year levels and surveyed. A sample of 1888 students was surveyed with a paper-based survey at school. The survey asked demographic questions and questions relating to alcohol, tobacco and other drugs; among these, students were asked a similar question to adults ‘Would you support a proposal that stops the sale of tobacco to those Tasmanians born after the year 2000?’ (Response options: yes—support, no—do not support and don't know/not sure); 92% of participants responded. Data were weighted by gender, age and educational sector to achieve a representative sample.
Support was summarised as proportions and 95% CIs overall and by demographic and smoking subgroups. For adults, a multivariable logistic regression was used to assess the ORs (±95% CI) of support by demographic subgroups and smoking status based on variables selected using all-subsets regression. For adolescents, multivariable multinomial logistic regression was used to assess the ORs (±95% CI) for levels of support (categories: ‘yes’, ‘no’ and ‘don't know/unsure’) by subgroups and smoking status for adolescents based on variables selected using all-subsets regression. All analyses were conducted using R Studio V.0.98.982.
Results
Among adults (18% were smokers), 75% supported the proposal. In a multivariable model including sex, age and educational attainment, those educated above year 12 had lower levels of support (OR 0.53, 95% CI 0.35 to 0.8) compared to those educated up to year 12. Those aged 50 years and over had lower levels of support (OR: 0.54, 95% CI 0.34 to 0.84) compared to those aged 30–49 years. No other differences between adult subgroups were observed.
Among adolescents (8% were smokers), 68% supported the proposal. Compared to not supporting the proposal, higher levels of support were associated with females (OR: 1.9, 95% CI 1.3 to 2.6) and non-smokers (OR: 6.2, 95% CI 3.9 to 10.0) and higher levels of uncertainty were associated with females (OR: 2.2, 95% CI 1.5 to 3.2) and non-smokers (OR: 2.9, 95% CI 1.7 to 5.0). Compared to supporting the proposal, uncertainty was higher among those born after the year 2000 (OR: 1.9, 95% CI 1.5 to 2.4) and lower among non-smokers (OR: 0.47, 95% CI 0.3 to 0.7). Support by demographic and smoking subgroups is provided in table 1.
Public support for the tobacco-free generation proposal in adults and adolescents
Discussion
Levels of support for the TFG proposal in these population groups were high, even among current smokers and those born after the year 2000. The surveys were conducted during a period of considerable print, radio and television coverage of the proposal, suggesting informed responses. This indicates that implementation of the proposal would be well accepted, potentially bringing the tobacco endgame another step closer. Enacting this proposal would most likely have a positive impact on the health of the population and also act as positive encouragement for tobacco endgame measures to be implemented elsewhere. The TFG proposal has not been implemented in any jurisdiction worldwide.
Apart from Tasmania, the only jurisdiction where public support for the TFG proposal has been examined is Singapore, where 70% (aged 18–65 years) supported the proposal, including 60% of current smokers.5
In Australia, a 2010 survey of Victorian adults found that 52% believed that 10 years was a reasonable time frame for a complete phasing out of tobacco sales.12 Internationally, studies have found that 45% of adults in England and 65% of adults in Hong Kong support a total ban on sales of tobacco within 10 years.13 ,14 In New Zealand, 59% of them aged 14–15 years supported living in a smoke-free country and 57% supported a ban on all tobacco sales within 10 years.15 The TFG proposal and the complete phasing out of tobacco sales represent different endgame strategies, but levels of support are high for both. These findings demonstrate a widespread desire for endgame measures in Australia and internationally.
A limitation of the TSHS was that only landline telephone users were surveyed; however, data weighting achieved a sample representative of the Tasmanian population on educational level, labour force participation, area-level socioeconomic status and smoking status (data not shown). Uncertainty was observed in the adolescent results, but was low in the adult survey. Whether this is due to greater uncertainty in adolescents or differences between paper-based (adolescents) and telephone-based (adults) surveys is not clear. A limitation of the ASSAD study is that 16 years and 17 years who are no longer attending schools were not captured by this study. In 2014, the retention rates for year 11 and 12 students was 69%.16
Conclusion
This study has demonstrated that there is strong public support for the TFG proposal in Tasmania, including from adult smokers and those born after the year 2000.
What this paper adds
A majority of Tasmanians, even smokers and young people directly affected by the TFG, support this proposed endgame strategy.
These findings should bolster international efforts to pursue endgame strategies even in populations where smoking is common.
Acknowledgments
The authors acknowledge all of the survey respondents for their participation and Cancer Council Victoria for producing the survey instruments, allowing us to adjust and use the Victorian Smoking and Health Survey in Tasmania.
References
Footnotes
Contributors ET was responsible for drafting the manuscript and conducting the analyses. All authors contributed to the interpretation of study findings and revisions of the manuscript.
Funding The TSHS was supported by Primary Health Tasmania under the Primary Health Networks Programme—an Australian Government Initiative. The Tasmanian component of ASSAD was led by Cancer Council Tasmania. It was supported by the Department of Health and Human Services, Department of Premier and Cabinet and the Department of Education. SG was supported by a National Heart Foundation of Australia Future Leader Fellowship (FLF 100446).
Competing interests None declared.
Ethics approval Ethics approval for the TSHS was provided by the Human Research Ethics Committee of the University of Tasmania (HREC H0015324). Ethics approval for the ASSAD survey in Tasmania was provided by the Human Research Ethics Committee of Cancer Council Victoria (HREC 1013).
Provenance and peer review Not commissioned; externally peer reviewed.