Commentary on White et al. (2011): Smoke-free policies within a comprehensive program coincident with major declines in teen smoking


In the early 1980s, the first state-wide mass media programs to reduce tobacco use were conducted in Australia, and a wait-list control design was used to demonstrate the effectiveness of this approach in reducing smoking prevalence [1,2]. Ever since, Australia has been widely recognized for its leadership and innovation in tobacco control. By 1990, tobacco advertising was banned from both broadcast and print media across the country. Over the ensuing years, the different Australian states and territories strengthened tobacco control efforts through consistent increases in tobacco excise taxes, progressive implementation of youth access laws and increased marketing restrictions at point-of-purchase locations and on billboards. Smoke-free policies were first implemented shortly after evidence was published linking such policies to teen smoking behavior [3,4]. The current paper by White et al. assesses the evidence for the effectiveness of these different policies on teen smoking using representative triennial state-wide surveys [5]. The degree of implementation of tobacco control expenditures and three major policies was coded for each year, and these variables were entered into multivariate models with outcome teen smoking rates.

The smoking data are interesting, with most jurisdictions showing increasing teen smoking during the early 1990s, peaking in 1996. This pattern is similar to the pattern seen in the United States over this same time-period. Many would expect the patterns to be different, as Australians were exposed to many more tobacco control campaigns and they were not exposed to either the innovative Camel or Marlboro advertising campaigns, seen widely as a cause for increased teen smoking in the United States in the early 1990s [6–8]. While declines were evident in youth smoking in the United States following the Master Settlement Agreement in 1999 [9], these were not the dramatic declines that White and colleagues report for the early years of the 21st century in Australia. Of importance is the considerable variability in the magnitude of the decline across the seven jurisdictions, from a low of 30% to a high of 56%. It would seem that state F is one of the states with the highest prevalence of teen smoking within Australia, although this prevalence of 16.8% appears to be similar to levels reported for California and New York in recent years [10]. It would also appear that 30-day prevalence among teens halved in state G over this short 6-year period and is now below 10%, an unparalleled achievement.

All three policy control variables increased strongly across the study period, although timing and patterns of increase across jurisdictions differed. After adjusting for all other variables, including demographic factors and a linear time trend, state-level marketing restrictions and clean indoor air laws were each significant predictors of reduced teen smoking while youth access restrictions were not. Marketing restrictions increased generally from low values in 1990 in all states to over 60% adoption by 2005. Smoke-free policies were implemented more abruptly, and were coincident with the decline in teen smoking: prior to 1999, there were no smoke-free policies at the state level. State G had the strongest early implementation and other states quickly followed to achieve an almost uniform 80% implementation by 2005. From the model, one would attribute to this change in smoke-free policies a 44% decrease in the odds of a teen smoking from 1999 to 2005. Thus, added to the significant tobacco control that was already in place, one can infer that a major variable associated with the dramatic decline in prevalence was the implementation of smoke-free policies across Australia.

This paper adds significantly to the evidence reviewed in the report on the effectiveness of smoke-free policies produced by the International Agency for Research on Cancer (IARC) [11]. This review noted that a number of studies have reported that, as jurisdictions consider and implement smoke-free policies, the prevalence of voluntary smoke-free homes within the jurisdiction rises. Studies comparing home smoking restrictions with work-place policies are consistent in identifying smoke-free homes as the more important of the two variables for reduction of teen smoking behavior. By maintaining a smoke-free home, parents are making a clear statement about their values with respect to smoking. When accompanied by a strong tobacco control program, a remarkable decline in teen smoking is possible.

Declarations of interest