Article Text
PDF
Abstract
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.
- public opinion
- end game
- public policy
Statistics from Altmetric.com
Introduction
There is increasing interest in novel policies to advance the goal of virtually eliminating tobacco use.1 2 One potential approach is through phasing out the retail sale of smoked tobacco products.1 3 By ending arrangements that currently allow retailers to sell these harmful products, phasing out retail sales would strongly signal that tobacco products are no ordinary product. It could potentially accelerate the denormalisation of smoking tobacco products and reduce relapse among former smokers and those trying to quit by reducing the visibility of and easy access to products in retail stores.4–6 However, a phase-out of sales would not be intended to prohibit the possession or use of smoked tobacco products.1 As such, some phase-out models might still permit individuals to grow tobacco or import limited quantities of tobacco products for their own use (as is currently the case for access to smokeless tobacco products in Australia7 8).
The ultimate realisation of a policy to phase out retail sales of smoked tobacco products requires consideration of the steps to reach it. Some jurisdictions, including the low-prevalence cities of Beverly Hills and Manhattan Beach in California, recently implemented a total ban on retail sales of tobacco from gas stations, convenience stores, pharmacies and grocery stores.9 10 However, in larger jurisdictions with slightly higher prevalence—such as Australia—phasing out sales by gradually reducing the number and types of outlets from which smoked tobacco products can be purchased may be more feasible.1 One incremental step could be to limit sales to stores that children cannot enter. Such a measure would be consistent with liquor licensing laws in most Australian jurisdictions, which only allow minors to enter licensed premises under certain conditions.11 Specialist tobacconist stores are not currently subject to these restrictions on who can enter, but this provision could be introduced. In the Australian state of Victoria, for instance, specialist tobacconists are defined as those that derive 80% or more of their turnover from the sale of tobacco products (which children cannot buy) and they are specifically required not to sell products for children or adolescents.12 Other store types prepared to restrict entry to under 18s (for instance) might also be considered eligible for licences.
Another step towards an eventual phase-out could be to expand retailer licensing and regulation. In Australia, five of the eight states and territories currently have a ‘positive’ licensing system requiring tobacco retailers to pay an annual fee, one state has a ‘negative’ licensing system, requiring a once-off notification but no annual fee, while two states (Victoria and Queensland) have no retail licensing systems.13 Implementation of a positive licensing system in all states and territories could facilitate a subsequent phase-out by allowing governments to reduce the number of retail outlets by gradually ending licence renewals and changing criteria for the types of retailers who can hold a licence. Increasing the cost of licences could also be used to encourage some retailers to voluntarily end selling tobacco products. As prevalence continues to fall,14 retailers will inevitably find it harder to sell adequate amounts of tobacco to return a profit.
One factor in determining the feasibility of phasing out retail sales of smoked tobacco products will be public support, including among the current smokers who will be directly affected.1 15 16 Exploring the public’s perception of the timeframe over which a phase-out should occur is also critical. Such evidence may be particularly important for sustaining political will against anticipated opposition from manufacturers of smoked tobacco products.1 16 17 In this study, we measured support for a proposal to phase out the retail sale of cigarettes—the most common form of smoked tobacco products in Australia18—and several measures to make progress towards this goal. This study was conducted in Australia in December 2019, following several decades of a comprehensive tobacco control programme. Over this time, tobacco advertising and promotion have been largely eliminated,19 20 including through plain packaging.21 Graphic warning labels have been required on tobacco packs since 2006.22 Smoking has been banned on public transport, at cinemas, in indoor workplaces and indoors at hospitality venues.23 Excise on tobacco has been increased regularly and substantially, such that cigarettes in Australia are now among the world’s most expensive.24 25 At the time of the study, access to nicotine vaping products was only permitted via importation from overseas retailers, although subsequent changes to regulations mean smokers can now access electronic nicotine delivery products from pharmacies with a prescription from their doctor.26 In addition, all smokers and quitters can access a free Quitline service and a range of other cessation services, including subsidised nicotine replacement therapy.27 In 2019, 11.0% of Australians aged 14+ were daily smokers.14
Method
Sample and procedure
In December 2019, we commissioned a cross-sectional study with n=1939 Australian adults using the probability-based online panel, Life in Australia™. The potential panel population included Australian adults contactable via landline or mobile phones, including those without internet access. Respondents completed the survey online (88%) or by telephone (12%). Among those invited, the completion rate was 76%.
Measures
Asked as part of a larger survey about multiple topics, respondents were informed that the policy support questions were being asked on behalf of Cancer Council Victoria. Respondents were first asked: Some people believe that there may come a time when it will no longer be legal to sell cigarettes in shops in Australia. Do you think this would be…? Response options were dichotomised for analysis as: ‘a good thing’ versus all other responses (‘a bad thing’, neither a bad thing nor a good thing, don’t know/refused). The second question defined what a ‘phase-out’ policy would mean (ie, removing cigarettes from the market over a set period so that eventually adult smokers could only buy cigarettes online from overseas companies). Respondents were asked whether they would support or oppose this phase-out policy: support (strongly or somewhat) versus all other responses. The third question asked: What timeframe would you think is appropriate in relation to phasing out the sale of cigarettes from shops?, with response options dichotomised as: within 5 years versus all other responses (‘within the next…10 years’, ‘15 years’, ‘20 years’, ‘not for at least 20 years’, don’t know/refused).
Three questions measured support for specific measures that could form part of a phase-out: (1) shop owners should seriously be thinking about transitioning out of selling cigarettes; (2) requiring shop owners to have a licence to sell cigarettes (just like for alcohol); and (3) restricting sales of cigarettes to places that children are not allowed to enter, with response options coded as: agree (strongly or somewhat) for (1) and support (strongly or somewhat) for (2) and (3) versus all other responses.
Statistical analysis
Analyses were conducted using Stata V.16.4. Data were weighted to be representative of the Australian population on demographic characteristics including region, socioeconomic status, gender, age, highest level of education, Aboriginal or Torres Strait Islander status, number of adults in the household, television viewing habits, digital affinity and telephone status.
Tables 1 and 2 present results from multivariable logistic regression models examining whether smoking status and demographic characteristics predicted responses. We report adjusted predicted probabilities, and adjusted ORs and 95% CIs for subgroup comparisons. The analytical sample was limited to those respondents who did not have missing data on any of the predictors, n=1874.
Smoking status and demographic predictors of support for phasing out the retail sale of cigarettes in Australia and perceptions of an appropriate timeframe for such a phase-out
Smoking status and demographic predictors of support for policies that could be implemented as part of a phasing out of retail sales of cigarettes in Australia
Results
Overall, 61.6% 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, 16.7% thought it would be ‘a bad thing’ and 21.3% thought it was neither a good nor a bad thing. When asked about a phase-out policy whereby products would be removed from the market over a set period so that eventually adult smokers could only buy cigarettes online from overseas companies, 50.7% indicated they were supportive and fewer than one-third (28.8%) were opposed. More than one-third (38.5%) thought it would be fair for the phase-out to occur within the next 5 years, and in total, 61.8% thought it should happen within 10 years.
Support was higher for some of the interim measures that could be implemented as part of a phase-out. Almost two-thirds agreed that shop owners should be thinking about transitioning out of selling cigarettes, and only 12.9% disagreed. Around three-quarters would support policies requiring retailer licensing and restricting sales to places that children are not allowed to enter, and only around 10% were opposed to these two policies.
As shown in tables 1 and 2, support for these policy options did not differ across demographic subgroups, except females were more likely than males to support retailer licensing (table 2). However, current smokers were significantly less likely than never smokers to support all six options and they were less likely than former smokers to support four of the six policy options (tables 1 and 2).
Discussion
Despite little public discussion about phasing out retail sales of cigarettes, such policies are already reasonably well supported by the Australian public, both overall and across demographic subgroups. The 62% of respondents who thought it would be a ‘good thing’ if there came a time when cigarettes were no longer available for sale in retail outlets approximated levels of support in recent surveys in the states of Western Australia and Victoria.28 29 Agreement was higher in a 2009 survey of Victorian adults when 72% thought it would be ‘a good thing’,30 and this may be attributable to far greater investment in televised antismoking campaigns at that time.31–33 Furthermore, the 2009 question referred to there being a time when ‘cigarettes will no longer be available for sale’ whereas the more recent surveys referred to a time when ‘it will no longer be legal to sell cigarettes’; the reference to (il)legality in 2019 may have reduced support.
Once a potential phase-out policy was defined in more detail, support was somewhat lower (51%). While defining a phase-out as occurring over a 5-year period made the policy more concrete, it may have also seemed less reasonable or feasible, given only 39% thought this sounded like a fair timeframe. On the other hand, naming the ways in which cigarettes would continue to be accessible (ie, ‘…buy cigarettes online from overseas companies’) may have reduced support among those whose preference would be for a complete sales ban. Support was higher for three specific measures that could form part of a phase-out.
Current smokers were, as expected, consistently the least likely to support each of the proposed measures.34 In recent studies of smokers and recent quitters in European Union countries17 and New Zealand,15 similar levels of support for a ban on tobacco sales within 10 years were observed (40% and 43%, respectively), although these questions explicitly specified that assistance to quit smoking would be provided. As in the current study, New Zealand smokers and recent quitters were also more likely to support specific measures to regulate supply such as allowing tobacco sales in stores that only adults can enter (55%) and requiring tobacco retailer licensing (70%).15 Further research is required to investigate factors that influence current smokers’ support for phase-out policies, including the extent to which support is predicated on the provision of quitting assistance.
One study strength is the large, representative sample that included current, former and never smokers. One potential limitation is that some respondents might not have understood the implications given these policy options have not yet been discussed publicly.15 16 Another limitation is that survey questions referred to ending the sale of ‘cigarettes’, whereas a phase-out would optimally extend to all forms of smoked tobacco. Similarly, respondents may have interpreted the question about restricting sales to venues that children cannot enter as referring only to stores where such limits currently exist, such as licensed premises and gambling venues. In practice, though, we envision that such a measure would also allow sales at specialist tobacconists, if restrictions on entry could be extended to these stores.
This study did not assess support for the full range of measures that could be implemented as part of a phase-out strategy. Future research could examine support for other policy options, including when a phase-out is defined as allowing access to lower risk forms of nicotine. Other research priorities include identifying optimal policy pathways to achieving a phase-out, including likely obstacles and their solutions such as financial barriers and enablers for tobacco retailers, especially following the financial impact on retailers of COVID-19 lockdowns in Australia. It will also be important to investigate the potential for increased illicit tobacco sales, and alternative sources to replace declining excise revenue for governments.
Key messages
What is already known on this topic
Australia is one of the jurisdictions in which, as smoking prevalence approaches 10%, novel policies such as phasing out the retail sale of smoked tobacco products are being considered.
Public support will be a critical factor in achieving the goal of phasing out sales, especially given anticipated opposition and lobbying from manufacturers of smoked tobacco products.
What important gaps in knowledge exist on this topic
Two recent state-based studies found that a reasonable proportion of adults in Australia are supportive of one day phasing out sales, but there are no data on support nationally or in relation to specific policies that may be implemented as part of a phase-out.
What this study adds
Using data from a nationally representative sample, this study found that the majority of respondents were supportive of one day phasing out the retail sale of cigarettes. Support was even higher for some of the interim measures that could facilitate a phase-out.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Cancer Council Victoria’s Human Research Ethics Committee (HREC: 0018). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We acknowledge the contribution of the Social Research Centre, whose probability-based online panel, Life in Australia™, was used to recruit respondents for this study.
References
Footnotes
Contributors All authors (EB, EI, MS, SJD, MAW) of this brief report directly participated in the planning, execution or analysis phases of the study and have read and approved the final version of this brief report.
Funding This study was funded by Cancer Council Victoria.
Competing interests EB, EI, MS, SJD and MAW are employed by a non-profit organisation that conducts public health interventions and advocacy aimed at reducing the harms of tobacco in the community, especially those pertaining to cancer.
Provenance and peer review Not commissioned; externally peer reviewed.