The Australian Government's new vaping policy should be part of a larger plan towards a tobacco endgame

The Australian Minister for Health and Aged Care, Mark Butler, made a strong push to address the growing problem of youth vaping in his speech at the National Press Club in May 2023.1 While new approaches to controlling youth vaping are urgently needed, it is critical that policy reforms to end the tobacco cigarette epidemic are also pursued with equal vigour — otherwise we risk shifting people currently using vapes to tobacco smoking. In this article, we argue that Australia should leverage its strong vaping regulation to commit in parallel to an ambitious commercial tobacco endgame to rapidly minimise smoking.

The end of recreational vaping?

Australia's new vaping control measures made headlines internationally,2,3 building on the current prescription‐only model for nicotine‐containing vaping products (NVPs) introduced in 2021. Poor enforcement of that model led to widespread illicit retailing of NVPs and easy accessibility for youth.4,5

The new reforms aim to prevent uptake and reduce current vaping among youth and young adults, by banning disposable devices and the personal importation of NVPs, restricting flavours, and introducing pharmaceutical‐like packaging and stricter quality requirements for all vaping products. The reforms also aim to maintain and improve access to NVPs for smoking cessation for people who smoke, by allowing all medical practitioners to prescribe NVPs without requiring any special authorisation.1,6

The success of the proposed changes will depend on several factors: whether the illicit vape market can be effectively controlled; the extent to which time and/or financial barriers might hinder adults who smoke from obtaining NVPs through a medical consultation; and the willingness of medical practitioners to prescribe them as cessation aids (while Therapeutic Goods Administration guidelines and standards are available for prescribers and dispensers, negative views among health practitioners may limit NVP availability via this pathway).7

If these factors are addressed, the new regulations could represent a positive step toward protecting young people from taking up vaping, while allowing adults who smoke to access NVPs for smoking cessation. However, we could and should do more, by strengthening the other half of the equation — tobacco policy itself. Otherwise, the lack of similar restrictions on combustible tobacco carries a risk of some people who currently vape, including youth, switching to tobacco cigarettes, which remain ubiquitous in retail environments. Strong vaping policies should be pursued, but improving public health overall will depend on how successful Australia is at also addressing the ongoing burden of smoked tobacco.

Tobacco smoking is a primary cause of morbidity, mortality, and health inequity

While youth vaping is of concern because it could lead to future disease burden, we should be equally, if not more, concerned about the burden from adults and youth who currently smoke. About 11% of Australian adults still smoke daily, according to the most recent national estimates from 2019, and tobacco remains the largest single cause of health burden in the population.8,9 In 2018, 8.6% of combined morbidity and mortality was attributed to tobacco, including 20 500 deaths, or 13% of all deaths.9

This burden is spread unevenly across the population because smoking has not declined at the same rate for everyone.8 The ongoing harmful impacts of colonisation are reflected in the higher smoking prevalence among Indigenous people; around 37% of this population smoke daily and 23% of Indigenous deaths are attributable to tobacco use.10,11 People experiencing socio‐economic disadvantage are disproportionately impacted by smoking — those residing in the most disadvantaged areas (Socio‐Economic Index for Areas [SEIFA] quintile 1) are more than three times as likely to smoke as those in the least disadvantaged areas (SEIFA quintile 5), with the most recent daily smoking estimates at 18% and 5% in the lowest and highest quintiles, respectively.8 Importantly, these gaps have not been decreasing over time, indicating that current policy approaches are not reducing smoking‐related inequity.8

The National Tobacco Strategy 2023–2030

The National Tobacco Strategy 2023–2030, which was released in May 2023, includes a target of less than 5% of the Australian population smoking by 2030.12 Although not described as such, this target is typically known as a “tobacco endgame”, whereby smoking reaches minimal levels in a population.13

The measures that have been announced as part of implementing the National Tobacco Strategy include additional funding for the Tackling Indigenous Smoking program, an increase in the current tobacco excise tax rate by 5% each year for the next three years, and standardisation of cigarette pack size.12 This builds on measures in progress, including a ban on menthol cigarettes, mandating health promotion inserts be added to cigarette packs, and printing health warnings directly on cigarette sticks.14

These strategies are incremental increases on existing policies, representing a continuation of the same approach that will likely take many years beyond 2030 to achieve the < 5% goal.15 Although new tobacco control policies are welcome, the policies announced lack the boldness of the Australian Government's approach to the issue of vaping, and the range of innovative policies that have been explored internationally to reduce smoking.

Further, the National Tobacco Strategy shows a lack of clear policies that have the most potential to rapidly reduce the wide inequity in Australian smoking rates. In parallel to the 2030 target of 5% in the Strategy is a specific target for Indigenous people of 27% smoking by 2030 — if this were achieved, it would reduce daily smoking in the Indigenous population to the level seen in the non‐Indigenous population 30 years ago, leaving wide (and some would say wider) health inequities.12,16

Greater urgency is needed given the health gains and reductions of health inequities that would result from a rapid reduction in smoking prevalence.

A commercial tobacco endgame: Aotearoa New Zealand's example

Australia is not unique in setting a 5% smoking prevalence target. In December 2022, the Aotearoa New Zealand Labour government in place at the time took forthright steps to meet this target by passing groundbreaking legislation.17 The law included three key policies:

• denicotinisation of all retail tobacco so that it is minimally addictive;
• a tobacco‐free generation, whereby it is illegal to sell tobacco to people born after 2008; and
• reducing the number of tobacco retail outlets by at least 90%.

The strength of these next‐generation supply‐sided actions proposed in the Smokefree Aotearoa 2025 Action Plan18 is that they shifted the focus from demand reduction policies that remain the mainstay in Australia, to addressing the core drivers that maintain the tobacco epidemic — the addictiveness of nicotine, the widespread retail availability of tobacco, and ongoing recruitment of young people to tobacco addiction. A recently published simulation study of these strategies in the Aotearoa NZ population estimated that an endgame of less than 5% smoking prevalence could be achieved within five years of implementation.19 The modelling also showed that the large resultant reductions in smoking prevalence, across all the population, translate to major reductions in the inequity in smoking rates experienced by Māori.19 The Action Plan's focus on reducing smoking inequity was the primary reason for its implementation into law.

Unfortunately, in November 2023 the newly elected Aotearoa NZ conservative coalition government announced it would repeal the legislation by March 2024.20,21 This triggered a global response from the public health community,22,23 which highlights the ambition of the smokefree legislation and the new standard it had set internationally24 in the fight against the tobacco epidemic.

The Aotearoa NZ approach also differs from that of Australia in its management of NVPs. Currently, NVPs are readily available as consumer products in Aotearoa NZ. As in Australia, the use of these products has increased rapidly in recent years, with an estimated 23% of 18–24‐year‐olds vaping daily in 2021–22.25 To rectify this, new measures were announced to reduce vaping among non‐smoking young people, including banning flavour names on products, introducing product safety requirements for single‐use devices, and imposing proximity restrictions on retailers of vaping products (eg, distance from schools).26 It is unknown whether NVP policy will also change under the new government, although there is no indication of plans to impose a medicinal model like that of Australia.

A unique opportunity for Australia

It is unclear whether Australia will follow suit on the short‐lived Aotearoa NZ tobacco endgame legislation in the near future. A tobacco‐free generation policy was put forward in the state of Tasmania in 2014 but was not implemented despite public support.27,28 The National Tobacco Strategy includes action points implying that new policies implemented internationally would be monitored and explored (action points 7.6, 8.1 and 8.6). Hence, the repeal of the Aotearoa NZ legislation may put Australia's position further into question.12 Similar policies, although not expected to be as impactful as the Aotearoa NZ package of measures, such as the stand alone tobacco‐free generation policy recently announced in the United Kingdom, could still provide international comparisons for Australia to evaluate and possibly adopt, if successfully implemented elsewhere.24 Furthermore, the United States is still actively considering implementing a denicotinisation policy.29

Despite the change in course in our neighbouring country's tobacco endgame strategy, there is a strong case now to tighten Australian tobacco policy (especially on the supply side). Australia has the opportunity to take the knowledge and expertise that led to the original passing of smokefree laws in Aotearoa NZ and address current inequities in smoking prevalence in Australia with innovative policies designed to rapidly reduce smoking across all populations. Conversely, there may be lessons that other countries such as Aotearoa NZ and the UK can learn from Australia's regulation of NVPs if the planned reforms successfully reduce vaping among young people.

Improving monitoring of both smoking and vaping in Australia is also needed to track the effects of policies, especially among groups that have high smoking rates but where limited in‐depth information is available from current national surveys.

The COVID‐19 pandemic saw each jurisdiction charting a different course to manage the pandemic. Some policies and jurisdictions were more successful than others. Sharing the lessons of what worked and did not work, and why, is an important part of transferring policy success that will be a key part of preparing for current and future public health challenges. As Australia and other countries chart their own courses to end the commercial tobacco epidemic, we argue that a stronger and more equitable tobacco policy is needed now in Australia to complement ambitious vaping policy, alongside rapid and ongoing knowledge and evidence transfer between countries.