17.6 Optimal investment in tobacco control

Following large-scale settlements of legal actions between US tobacco companies and state attorneys-general, the US Centers for Disease Control issued a series of guidelines for US states to aid budget allocation in tobacco control.¹ Best Practices for Comprehensive Tobacco Control Programs included recommended spending levels for each of the 50 states of the US and the District of Columbia taking into account the costs of administering each component of a comprehensive tobacco control program, and the costs of delivery determined by the numbers of people in each target group in that jurisdiction. Annual costs to implement all the recommendations ranged from $5 to $20 per capita. The Centers for Disease Control updated the guidelines in 2007² and again in 2014.³ The 2014 report concluded that the annual investment needed to implement the recommended program components of a comprehensive tobacco control program in the US was estimated to be a minimum of $7.41 per capita, with a recommended investment of $10.53 per capita.³

In 2003, after release of the first Best Practices report, the Australian National Expert Advisory Committee on Tobacco (NEACT) undertook a project to adapt and tailor the methods used in the US report. It then issued recommendations for annual expenditure on tobacco control for Australia and each Australian state. 

 A detailed breakdown of the resources required for effective tobacco control with recommended national expenditure for programs, enforcement of policies and research was provided in the resource documents supporting the Australian National Tobacco Strategy.⁴ The amounts recommended for each component of a comprehensive tobacco control program are summarised in Table 17.6.1.

Source: National Expert Advisory Committee on Tobacco, Guide to Planning and Investment in Tobacco Control, 2004,⁴  Section 2.1

Table 17.6.2 summarises the total recommended expenditure on tobacco control for each state and territory and for Australia, contrasted with actual expenditure in 2007–08.⁵ Expenditure between $4 and $10 per capita was the recommended level based on the NEACT analysis. The actual expenditure averaged $2.23 per capita in 2007–08. Total expenditure was $47.3 million. Spending in New South Wales and Western Australia was just below the lower recommended level, but in other states expenditures were considerably less than even the lower recommendation. Expenditure in 2007-08 would have been substantially lower than the level currently recommended in the revised Best Practices report.

Tobacco control in Australia has been under-funded by international and Australian private and public sector standards.⁶ Economic analysis also suggests that overall expenditure is much too low given the very high potential rates of return.^{7, 8} Even in Western Australia, which has always had one of the highest per capita rates of spending on tobacco control of any jurisdiction in Australia, Collins and Lapsley concluded that a ten-fold expenditure increase from 2003 levels could be justified if a minimum social return of 10% was required for public expenditures. 

In 2009, the National Preventative Health Taskforce called for implementation of more comprehensive and intensive tobacco control interventions in Australia in order to reduce the prevalence of smoking to less than 10% by 2020.⁹ The measures proposed included: increases in excise and customs duty on tobacco products, increased spending on anti-smoking marketing campaigns, modernisation of legislation to eliminate remaining forms of tobacco promotion and strengthened services and treatments for smokers wishing to quit. In April 2010,¹⁰ the then Prime Minister Kevin Rudd announced that the government would increase tobacco excise by 25%, and legislate to ensure that cigarettes will be sold in plain paper packaging and boost investment in anti-smoking advertising. In its May 2010 response to the National Preventative Health Taskforce report¹¹ the government indicated that it would spend an additional $85 million over four years on anti-smoking social marketing campaigns and initiatives to reduce smoking among disadvantaged communities.¹¹ The increase in tobacco control funding announced averaged $21.25 million per year. (Adding this to existing funding of $47.3 million gave an estimated expenditure of approximately $3.23 per capita).

In 2019, the Public Health Association of Australia, the Heart Foundation and the Cancer Council jointly proposed a commitment from the Commonwealth Government to provide $50 million per annum over four years for campaign and cessation programs to implement the next National Tobacco Strategy (NTS). It recommends that investment should be allocated to the following initiatives:

• $25m per annum to reinstate, and maintain for the period of the NTS, a population based TV-led National Tobacco Campaign, targeting adult tobacco users in all states and territories which is evidence-based in both creative development and audience exposure, and supported with rigorous developmental research and campaign evaluation.
• $10m per annum to create and fund a dedicated National Cessation Strategy within the National Tobacco Strategy to facilitate a consistent, evidence-based national approach to smoking cessation service provision. This would include the development and dissemination of national clinical guidelines and program support to embed the treatment of tobacco dependence into health services, primary care, and community and social service organisations as part of routine care, and the provision of a national Quitline™ as a referral, training and behavioural support provider.
• $15m per annum to specific, targeted programs that will provide additional support to groups in the population experiencing the highest levels of disadvantage. This will primarily be done through partnerships with the public health and community service sectors to provide direct services to high needs populations.

The proposal notes that despite the increasing revenue collected from tobacco, and the strong evidence for the impact of public education (especially with disadvantaged groups), in 2019 funding for television-led public education campaigns was at its lowest point in 20 years (see also Section 14.3), which has coincided with an absence of significant decline in smoking prevalence between 2013 and 2016. The funding proposed comprises less than one-third of one percent of the $48.6b in revenue from tobacco excise and customs duty that the Government expects to receive over the next three financial years.¹²

Relevant news and research

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References

1. Centers for Disease Control and Prevention. Best practices for comprehensive tobacco control programs. Atlanta Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1999. Available from: https://files.eric.ed.gov/fulltext/ED433332.pdf.

2. Centers for Disease Control and Prevention. Best practices for comprehensive tobacco control programs—2007. Atlanta: Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2007.

3. Centers for Disease Control and Prevention. Best practices for comprehensive tobacco control programs—2014. Atlanta, United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Available from: https://www.cdc.gov/tobacco/stateandcommunity/best_practices/pdfs/2014/comprehensive.pdf.

4. Ministerial Council on Drug Strategy. Australian national tobacco strategy 2004-2009: Guide to planning and investing in tobacco control.  2005.

5. Australian Institute of Health and Welfare. Public health expenditure in Australia, 2007-08. Health and Welfare Expenditure Series no. 38, Cat. no. HWE 47.Canberra: Australian Institute of Health and Welfare, 2009. Available from: https://www.aihw.gov.au/reports/health-welfare-expenditure/health-expenditure-australia-2007-08/contents/table-of-contents.

6. VicHealth Centre for Tobacco Control. Tobacco control: A blue chip investment in public health. Melbourne: The Cancer Council Victoria, 2003. Available from: https://www.tobaccoinaustralia.org.au/downloads/chapters/TCMasterApril2003.pdf.

7. Collins D and Lapsley H. Counting the costs of tobacco and the benefits of reducing smoking prevalence in Victoria. Victorian Department of Human Services, 2006. Available from: https://www2.health.vic.gov.au/about/publications/Factsheets/Counting%20the%20costs%20of%20tobacco%20and%20the%20benefits%20of%20reducing%20smoking%20prevalence%20in%20Victoria.

8. Collins D and Lapsley H. Counting the costs of tobacco and the benefits of reducing smoking prevalence in Western Australia. Monograph series, no 4. Perth: The Cancer Council Western Australia, 2004.

9. National Preventative Health Taskforce. Australia: The healthiest country by 2020. National preventative health strategy - the roadmap for action. 20 june 2009. Canberra: Commonwealth of Australia, 2009. Available from: https://extranet.who.int/nutrition/gina/sites/default/files/AUS%202009%20National%20Preventative%20Health%20Strategy.pdf.

10. Rudd K, Swan W, and Roxon N. Prime minister, treasurer, minister for health. Anti-smoking action., Office of the Prime Minister, Editor 2010: Canberra. Available from: https://pmtranscripts.pmc.gov.au/release/transcript-17255.

11. Australian Government. Taking preventative action: Government's response to Australia: The healthiest country by 2020.  2010. Available from: https://apo.org.au/sites/default/files/resource-files/2010/05/apo-nid21989-1365646.pdf

12. Public Health Association of Australia, Heart Foundation, and Cancer Council. Resourcing the national tobacco strategy to reduce smoking among those who need help the most.  2019. Available from: https://treasury.gov.au/sites/default/files/2019-03/360985-PHAA-NHF-CC-joint-submission.pdf.