Selling tobacco. CanAct. The greater the availability of tobacco, the more people smoke. Beat cancer together

Transcription

1 Selling tobacco Anywhere, anytime HARMFUL not helpful The greater the availability of tobacco, the more people smoke CanAct Beat cancer together

2 Contents Executive summary 1 Recommendations 3 Introduction 4 How does the retail environment influence smoking? 6 Tobacco retailing in NSW 9 Cancer Council NSW audit of tobacco retailers 11 The case for tobacco retail reform 16 Conclusion 20 References 22 Suggested citation Fry R, Williams K, Tang A, Burton S, Walsberger S, Soulos G, Egger S, Chapman K. Selling tobacco anywhere, anytime: harmful not helpful. Sydney: Cancer Council NSW, Acknowledgments The study was funded by Cancer Council NSW which receives fundraising support from many large and small retailers. Cancer Council NSW would like to thank Dr Becky Freeman for reviewing the literature on the tobacco retail environment and Michael Narag and Maria Uribe for research assistance with the literature review. A sincere thank you also to Alicia Harper, Susanna Lawrence and Charlotte Allen for coordinating the production and distribution of survey materials. We are indebted to Cancer Council NSW volunteer data collectors and staff for their considerable time and effort in supporting and conducting the survey. Glossary Entrenched smokers: Smokers who are not considering quitting and who typically plan cigarette purchases in advance to buy at a lower price and avoid running out. Non-tobacco smoking product: Any product (other than a tobacco product) intended to be smoked, including any product known or described as herbal cigarettes. 1 Smoking accessories: Cigarette papers, pipes, cigarette holders, hookahs, water pipes and any other smoking implements. 1 The Public Health (Tobacco) Act 2008 (NSW) 1 does not include matches or lighters in the definition of smoking accessories, which means they can be lawfully displayed. Specialist tobacconist: A person who operates a business which, in the 12 months preceding 25 September 2008 (the date the Public Health (Tobacco) Act 2008 was introduced to Parliament), obtained at least 80% of its gross turnover from the sale of tobacco, non-tobacco smoking products or smoking accessories. 1 The person has also been approved as a specialist tobacconist by the NSW Ministry of Health. Tipping point smokers: A person who does not intend to smoke at all (e.g. attempting quitters who relapse) or does not intend to smoke very much. Both are more likely than entrenched smokers (see definition above) to buy cigarettes on impulse and are more likely to be susceptible to point of purchase cues to smoke. Tobacco products: Tobacco, cigarettes, cigars or any other product containing tobacco, designed for human consumption or use. 1 Tobacco retailers: Stores and other outlets selling tobacco, including supermarkets, tobacconists, petrol stations, convenience stores, bottle shops, and cigarette vending machines in pubs and clubs.

3 Executive summary Tobacco, a product that kills half its long-term users and is Australia s leading cause of preventable death and disease, is startlingly easy to buy. Cigarettes are available anywhere, anytime a legacy of the time when society was ignorant of their dire health effects. There are more than five times as many places to purchase tobacco in NSW as there are places to buy prescription medicines. Tobacco retailers are also less regulated than sellers of second-hand goods. To date, tobacco control policies have concentrated on reducing the demand for tobacco products. Apart from a long-standing ban on sales to under-18s, there are few limits on supply, such as who may sell tobacco, where and when they may sell, or limits on the number of outlets selling tobacco. Tobacco use remains an urgent health and social problem and there is enormous potential for retail reform to help solve it. In the state plan, NSW 2021, the NSW Government has targets to lower smoking rates by 3% for non-aboriginal people and 4% for Aboriginal people by Under the National Partnership Agreement on Preventative Health, the Government has committed to reduce daily smoking among adults to 10% or lower by The NSW Minister for Health has endorsed the National Tobacco Strategy , thereby undertaking to consider further options for tobacco retailer licensing and to commission research on regulatory approaches to control the number and type of tobacco outlets. Cancer Council NSW has examined the evidence relating to the retail environment and smoker behaviour and has conducted an audit of 1,739 tobacco outlets in NSW. This report presents our findings, which show targeted reforms to the retail sector could make it easier for smokers to quit and remain quit, help stop young people taking up smoking and protect communities we have so far failed to protect. Developing a policy and research strategy for retail reform will require partnerships across government and nongovernment organisations. As a first step, Cancer Council NSW recommends the Minister for Health establish a Ministerial taskforce. This taskforce would explore, evaluate and advise on policies designed to reform the tobacco retail environment and effectively accelerate declines in smoking prevalence. How does the retail environment influence smoking? There is evidence that high retail density and widespread distribution contribute to smoking, though there are some limitations to this evidence. There is Australian and international evidence suggesting tobacco outlet density is higher in disadvantaged communities. There is international evidence indicating the presence of tobacco retailers near schools contributes to tobacco purchase and smoking prevalence in adolescents. There is some evidence that people trying to quit smoking are more likely to relapse if they live close to retailers selling tobacco. There is evidence that convenience, route and impulse outlets (e.g. convenience stores, small grocers, petrol stations, bars, pubs and clubs) may disproportionately contribute to unplanned purchases of tobacco products by people not intending to smoke (e.g. quitters who relapse) or people smoking more than they intend. There is consistent evidence that consuming alcohol, especially in social settings like bars and clubs, increases the amount of smoking, increases the likelihood of non daily smokers smoking and undermines quit attempts. There is strong evidence that removing point-of-sale displays will reduce retail cues to smoking. However, there is emerging evidence from NSW indicating it will not completely eliminate retail cues. The mere sight of a retail outlet, particularly tobacconists and liquor stores, prompts some smokers and quitters to think about smoking or buying cigarettes. This highlights the potential public health benefits of policies to limit the number and/or type of tobacco outlets. 1

4 Cancer Council NSW audit of tobacco retailers Cancer Council NSW used the Retailer Notification Scheme to better understand the structure, density and distribution of the tobacco retail sector in NSW and to find out whether retailers were complying with the new laws under the Public Health (Tobacco) Act 2008 (NSW). We also used it to measure differences in cigarette prices between retailers. Using the list of notified retailers obtained under a Government Information (Public Access) request (formerly Freedom of Information), we randomly selected a sample of postcodes in urban and regional NSW. Thanks to 166 volunteer and staff data collectors, we visited and made observations in 1,739 retail outlets. More than one in four audited tobacco retailers (26.6%) did not comply with the requirements of the Act, either because they had not notified under the Retailer Notification Scheme or because they failed to comply with in-store requirements, or both. The most commonly observed breach of the legislation was failure to display a Smoking kills warning sign (11.9% of retailers). We found that the Retailer Notification Scheme does not accurately record the number, type and location of tobacco retailers in NSW. Some retailers were not on the list and the audit indicated there is one unlisted retailer for about every 13 listed retailers. Unlisted retailers were more likely to breach the legislation. The list of notified retailers also included a large number of multiple listings and out-of-date retailer records. Although the list received from the Ministry of Health contained 13,439 retailer records, our results estimate the actual number of active tobacco retailers in NSW, as of February 2013, is 9,597. Convenience, route and impulse retailers (e.g. licensed premises, convenience stores, petrol stations and newsagents) represented 78.3% of tobacco outlets, despite the fact that supermarkets and tobacconists dominate market share. This is a striking finding, as previous research suggests convenience, route and impulse retailers disproportionately contribute to purchases by tipping point smokers, such as people not intending to smoke and attempting quitters who relapse. Retail: the weak link Retail availability of tobacco is the weak link in tobacco control. Public health experts have proposed various strategies to limit supply, including mandated quotas, nationalising the tobacco industry, banning sales to anybody born after a certain year, requiring smokers to have a licence to purchase tobacco, phasing out retail sales completely and limiting the number, type, location and/or opening hours of outlets. Cancer Council NSW believes the most feasible approach is incremental, and the evidence supports the introduction of limits on the number, type and location of outlets. Stronger regulation would further reposition tobacco as the harmful product that it is and contribute to denormalisation of smoking and tobacco products. Public support for stronger regulation of tobacco retailing is high. In a recent Cancer Council NSW community-based survey of 2,473 people, 79% of respondents supported policies requiring retailers to have a licence to sell tobacco products, in the same way retailers need a licence to sell alcohol. Licensing has higher levels of support than point-of-sale display bans and plain packaging, which are already in place. Kids are more likely to take up smoking when there are more tobacco outlets closer to their school. Cigarette prices varied between different types of outlets. Prices were cheaper, on average, in postcodes with a higher proportion of children in the population and in disadvantaged areas. 2

5 Recommendations Addressing the retail availability of tobacco in NSW could accelerate declines in smoking prevalence, support people more effectively to quit smoking, promote health in socially disadvantaged areas and protect children from tobacco. A taskforce for tobacco retail reform Cancer Council NSW recommends the NSW Minister for Health: 1. Convene a taskforce under the auspices of the Minister s office to explore, evaluate and advise on policies for tobacco retail reform that will most effectively accelerate declines in smoking prevalence. 2. Require the taskforce to base their advice to the Minister on the best available evidence. 3. Include the following responsibilities among the taskforce s terms of reference: commission research to more closely assess the impact of retail distribution on smoking in the NSW context; consult with the public and affected retail sub-sectors; assess the potential for a positive licensing scheme, with associated conditions of licence and an annual fee, as a means to boost resources for monitoring and enforcement; develop strategies to restrict the number, type and distribution of retail outlets; and outline the essential elements of a regulatory scheme that would effectively address the impact of tobacco retail availability on smoking rates. 4. Appoint a maximum of nine members to the taskforce, including the chair, with expertise in: tobacco control (one or two members); public health, particularly preventive health in Aboriginal and disadvantaged communities (one or two members); public health law and regulation (one member); academic retail marketing research relevant to the terms of reference (one member); and the retail sector (maximum of three members, chosen to reflect the diversity of the retail market). 5. Exclude from taskforce membership (but include in consultations) individuals and/or organisations that receive funding from tobacco companies or are directly affiliated with those companies. 6. Request the taskforce to report their findings within one year of being convened. Strengthening compliance with existing tobacco retail laws Cancer Council NSW recommends the NSW Ministry of Health: 7. Introduce systems to ensure notifications under the Retailer Notification Scheme are accurately collected and recorded, so as to provide up-to-date information about outlet address, changes in business ownership and whether the outlet continues to sell tobacco. 8. Provide a publicly accessible, searchable online database of all notified tobacco retailers in NSW. 9. Provide publicly accessible annual reports with quantitative measures of retailer monitoring, compliance, prosecutions and convictions for each Local Health District. 3

6 Introduction Australia is a world leader in reducing smoking. In NSW, smoking prevalence is at a historic low with 14.7% of people aged 16 and over now current smokers, 2 compared to 41% of men and 30% of women in Lower smoking rates have been achieved through a series of actions over many years, including: bans on tobacco advertising, promotion and sponsorship; mass media campaigns about harms to health; taxes to increase tobacco prices; health warnings on cigarette packs; free advice and support to quit smoking; subsidised pharmacotherapies to help with quitting; laws that ensure tobacco must be out of sight in retail outlets; and legislated smoke-free areas, both indoors and outdoors. Despite enormous progress, however, more than 800,000 people in NSW continue to smoke. 2,4 Tobacco is a powerfully toxic product and remains Australia s leading cause of preventable death and disease. 5 It kills more than 5,000 people per year in NSW 20 times the number killed by motor vehicle crashes. 6,7 One in two long-term smokers will die from smoking-related causes. 8 Moreover, the impact of smoking is increasingly concentrated among the most disadvantaged members of our community. Aboriginal people in NSW have more than twice the smoking prevalence of non-aboriginal people 9 and residents of low socio-economic status (SES) neighbourhoods have more than twice that of high SES neighbourhoods. 10 Among very disadvantaged people, (e.g. people with mental health issues and injecting drug users), smoking rates of 66% 11 to 94% 12 have been reported. The NSW state plan, NSW 2021, has a target to reduce smoking rates by 3% by 2015 for non-aboriginal people and by 4% for Aboriginal people. 13 NSW is also committed to the target set out in the National Partnership Agreement on Preventative Health to reduce daily smoking among adults to 10% or lower by There is still much work to be done. We must find new ways to make it easier for smokers to quit and remain quit, to stop young people taking up smoking, and to protect communities we have so far failed to protect. Retail: the next step To date, tobacco control efforts have concentrated on reducing demand (i.e. discouraging people from wanting to buy and smoke cigarettes). Apart from a long-standing ban on sales to under-18s, limits on the sale of tobacco have been neglected. Cigarettes are widely available in corner shops, supermarkets, petrol stations, newsagents, tobacconists, pubs, clubs and bottle shops. The ban on retail displays (known as point-of-sale displays) is an important step forward. NSW and other Australian states have introduced this legislation over the past few years and are among the first jurisdictions in the world to do so. Along with plain packaging, this effectively removes one of the remaining forms of cigarette promotion. However, these provisions do not restrict the supply of tobacco. Existing legislation places very few restrictions on the type and number of outlets where tobacco may be sold. It is still available anywhere, anytime. 15 It is an anomaly that such a dangerous product is so easy to get. The ubiquity of tobacco is out of step with other products that are legal, yet potentially lethal. Alcohol, for example, is regulated by strict licensing conditions. There are restrictions on the type of outlet that can sell alcohol, where outlets can be located, what hours a retailer may operate and what training staff must undertake. Medicines are also subject to laws about where and by whom they can be sold. Even businesses selling second-hand musical instruments require a licence, but not those selling cigarettes. 16 Tobacco: available anywhere Tobacco, a product which is harmful by nature and kills half its long-term users, is much more widely available than other goods which are not by their nature harmful to health. At 30 June 2012, there were 13,439 notified tobacco retailers in NSW. # This is compared to just 1,831 registered pharmacy businesses 17 and 1,129 Australia Post outlets. 18 # As noted later in this report, the number of tobacco retailer notifications as provided to Cancer Council NSW by the Ministry of Health (13,439) overestimates the number of currently active retailers. However, our best estimates suggest the actual number is still close to 10,000. 4

7 Reform of the tobacco retail environment would help achieve the NSW Government s policy goals. The NSW Cancer Plan includes policies to further restrict the availability and supply of tobacco products as a key activity in its goal to reduce smoking prevalence. 19 In November 2012, the NSW Minister for Health and her counterparts from other states endorsed the National Tobacco Strategy This Strategy includes the following actions relating to tobacco retailing: Consider and explore further regulatory options to implement tobacco licensing schemes for retailers and wholesalers (Responsibility: State and territory governments). Commission research to examine the potential benefits, feasibility and best practice regulatory approaches of placing controls on the number and type of tobacco outlets in the community (Responsibility: Australian Government; state and territory governments; non-government organisations). The National Tobacco Strategy notes that a positive licensing scheme, which links compliance with tobacco control legislation to the right to sell tobacco products, is generally recognised as best practice. 20 A positive licensing scheme is one that requires a retailer to gain prior approval to sell tobacco. 21 In 2002, the Commonwealth Department of Health and Ageing commissioned the Allen Consulting Group to review the feasibility, cost-effectiveness and public health benefits of registration and/or licensing schemes for tobacco retail outlets in Australia. The review found a strong case for positive licensing of tobacco retailers, not only as a means to improve monitoring and compliance but also to reinforce the understanding that selling tobacco is a privilege, not a right. 21 the conditions of sale. Queensland and Victoria do not have licensing or notification schemes, 27,28 and as yet there is no jurisdiction in Australia that limits the type or location of tobacco outlets. Similarly, no jurisdiction places caps on the number of available licences. Regulating the tobacco retail environment can send an unambiguous public signal that governments regard tobacco as an exceptionally harmful product. 29 The widespread availability of tobacco sends a mixed message to the community, diminishes the likelihood of successful quit attempts and undermines efforts to denormalise smoking. Cancer Council NSW believes there are opportunities to reduce tobacco use and accelerate progress towards government targets through reform of the retail environment. This report: summarises existing evidence on the relationship between the retail environment and smoking; describes current arrangements for tobacco retailing in NSW; reports the results of an audit of retail outlets selling tobacco; and provides recommendations for reducing smoking in the community through tobacco retail reform. Positive licensing schemes now exist in the Australian Capital Territory, Northern Territory, South Australia, Tasmania and Western Australia Licence fees range from $200 per year in the ACT to $302 in Tasmania. Some states also make registers of retailers available to the public. Western Australia, notably, has a searchable online register of retailers. NSW has a negative licensing scheme where retailers do not need a licence to sell tobacco. However, they are required to notify the government that they intend to sell the product and can be prohibited from selling if they repeatedly breach Smokers are less likely to quit when they live closer to tobacco outlets. 5

8 How does the retail environment influence smoking? Density and distribution The presence of cigarettes in every corner shop is a legacy of the time when society was ignorant of their dire health effects. Historically, tobacco has been treated like bread, milk, chewing gum, or any other fast-moving consumer good, with widespread distribution through a variety of retail outlets. Even without product displays, the widespread availability of tobacco is itself a form of promotion. Retail access is likely to prompt cigarette purchase by providing environmental cues, to facilitate smoking by making it easy to buy tobacco and to normalise smoking by sending a signal that tobacco is like any other product. 15,29-33 In a population-based NSW survey, 87.5% of smokers reported they were within walking distance of a retail tobacco outlet during their daily activities. 15 When asked what they would do if this was not the case, 7.8% said they would try to quit and 20.0% would cut down. 15 * In a prospective diary-style study, also in NSW, participants recorded their smoking and cigarette purchases at four-hourly intervals over four days. 32 * They saw cigarettes for sale in more than 40% of four-hour periods spent outside the home. In international studies, high retail outlet density (the number of tobacco retailers per area or per population) has been found to be associated with smoking in both adolescents and adults A study in Massachusetts, for example, found people living in communities with a higher density of tobacco retailers were more likely to be smokers, after adjusting for other individual and community-level risk factors. 36 A Californian study found the density of convenience stores and distance to the nearest convenience store were associated with the number of cigarettes smoked per day. 34 Most studies on retail density have been cross-sectional and have been conducted in the United States and other jurisdictions where point-of-sale promotions remain. Causation cannot be assumed and their findings cannot be directly translated to the NSW retail environment. However, place is one of the 4Ps that make up any marketing strategy (along with product, price and promotion 40,41 ) and the literature relating to tobacco density and distribution points to the need to consider place or retail geography in tobacco control. Young people Among young people, the density of retailers and their proximity to schools has been shown to influence smoking and tobacco purchase. 35,37,38,42-45 Studies in Canada and New Zealand found access to tobacco retailers made it more likely that high-school aged children bought their own cigarettes. 42,45 In California, smoking prevalence was higher in schools with more than five tobacco outlets within walking distance than in schools without tobacco retailers nearby. 35 New York research showed an association between high tobacco retail density and young people believing that smoking made them look cool and helped them fit in. 43 Research has established that adolescents aged 11 to 14 who perceive cigarettes are easily available are more likely to experiment with smoking and to progress to heavier smoking. 46,47 Disadvantaged neighbourhoods Disadvantaged communities are more likely to have a higher concentration of tobacco retail outlets. 35,38,48-54 Evidence of this relationship has been found in numerous studies internationally, 35,38,49-51,53,54 and recently in NSW 52 and WA. 48 The NSW study found higher tobacco retail density in disadvantaged local government areas (as measured by socio economic indexes for areas, or SEIFA 55 ) and in remote areas. Both associations were significant after controlling for smoking prevalence, indicating higher outlet density is not simply due to higher demand. 52 Similarly, the density of tobacco outlets in WA was found to be more than four times as high in suburbs and towns in the bottom quartile of SEIFA scores than in those in the top quartile. 48 A nation-wide US study found areas of disadvantage had higher densities of tobacco retail outlets regardless of whether the community was urban or rural. 51 A study in New Jersey showed income was the strongest and most consistent predictor of tobacco outlet density, with higher tobacco outlet densities in geographic areas with lower median household income. 54 Tobacco outlet density was also likely to be higher in areas with higher percentages of ethnic minorities. 54 Another New Jersey study found for every US$10,000 increase in median household income, there was a 0.9 unit decrease in tobacco outlet density. 56 Many of the studies on retail density and disadvantage have controlled for smoking prevalence. This accounts for the fact that higher outlet density in disadvantaged neighbourhoods is partly due to higher prevalence of smoking and therefore higher retail demand. Whether or not the relationship between density and disadvantage is causal, the correlation is cause for concern as it suggests the retail environment adds to the many social and environmental factors known to make it more difficult for disadvantaged people to give up smoking. 57 Attempting quitters There are few studies on the effect of the tobacco retail environment on cessation attempts, but some research suggests easy access makes it harder to quit. In Texas, attempting quitters living less than 500 metres from the nearest tobacco retailer were less likely to remain abstinent during the six month-period after a quit attempt. The effect was even stronger for those less than 250 metres away. 58 Retailer density, unlike proximity, did not affect quitting success. This study is notable because of its prospective, longitudinal design, its finding of a dose-response relationship and because it used physical tests to verify participants self-report of their smoking status. 58 *This study received funding from Cancer Council NSW. 6

9 T HE AVAI L ABI L ITY OF TOBACCO IN F LU ENCE S... Whether How many Whether PEOP LE PEOPLE PEOPLE Smoke Smoke Quit Kids are more likely to take up smoking... More people are likely to smoke... Smokers are less likely to quit... When there are more tobacco outlets closer their school. When there are more tobacco outlets closer to where they live. When they live closer to tobacco outlets. a nd t his in cre as e s THE RI SK o f c a n c e r 7

10 A study in Finland, with a long follow-up period, found living close to a store selling tobacco and having one or more stores within 0.5 km were associated with lower quitting success among men who were moderate or heavy smokers, but not among women or lighter smoking men. 59 Type of outlet Lower-priced outlets There is evidence that smokers use different types of retail outlets in different ways. Supermarkets and tobacconists generally charge lower prices, 60 and a prospective diary style study in NSW found smokers made larger purchases at these outlets than at other outlets, although the difference was not significant among attempting quitters. 31 By charging lower prices, supermarkets and tobacconists may encourage price sensitive smokers to buy larger quantities and to smoke at higher levels. These outlets may be disproportionately used by entrenched smokers who are likely to purchase on price, plan ahead to avoid stock-outs and buy in bulk. 61 Convenience outlets A NSW diary-style study including 1,112 smokers drawn from a population sample, and 2,287 attempting quitters drawn from Quitline callers, was undertaken in NSW. 31 Participants recorded when and where they obtained tobacco products, and how much they smoked, at four-hourly intervals over four days. Lighter smokers were more likely than heavier smokers to buy tobacco products at convenience stores, bars, pubs and clubs, suggesting these outlets may disproportionately contribute towards impulse purchases and confirming the link between alcohol and smoking. 31 Convenience-type outlets appear likely to encourage purchase by quitters who relapse. Participants in a NSW telephone survey who had tried to quit within the previous 12 months were asked where they usually bought cigarettes and where they bought their first relapse-related cigarettes. 15 Supermarkets comprised about half of usual purchases for this group, but only 25.7% of relapse purchases. Service stations and convenience stores accounted for 23.8% and 23.2% of relapse purchases respectively. 15 Licensed premises Consuming alcohol, especially in social settings like bars and clubs, increases the amount of smoking and the likelihood of non-daily smokers smoking. It is also known to undermine quit attempts The disinhibiting effect of alcohol and the presence of other smokers are contributing factors, but smokers report that access to purchase also increases consumption. Twenty two per cent of surveyed smokers in NSW said having cigarettes sold on the premises meant they smoked a lot more and 17% a little more, with those aged 18 to 39, women and light smokers more likely to report increased consumption in bars, pubs and clubs. 15 Point-of-sale displays A compelling body of evidence contributed to the adoption of retail display bans by NSW and other Australian states and territories. A 2009 systematic review concluded that point of sale display bans are justified on the grounds tobacco promotion has been clearly proven to influence children to begin smoking. 65 Visible tobacco displays are known to contribute to unplanned purchase, make quitting more difficult, 69,70 and increase the amount of smoking and the likelihood of purchasing. 32 Studies in Ontario, Canada and Melbourne have found full display bans achieved high compliance. 71,72 In contrast, a partial display ban in New Zealand was found to be difficult to implement and achieved limited compliance. 73 Compliance varied between retailer types, with small local general stores and convenience stores least compliant. 73 Effects of retailer access versus point-of-sale displays As noted previously, one of the difficulties in determining the relevance of international research to NSW is that many studies have been done in jurisdictions where point-of-sale displays may confound the effect of retailer density and proximity on smoker behaviour. It is unclear whether, in the absence of all point of sale marketing, the abundance of tobacco retail outlets will still trigger tobacco purchases and sabotage quit attempts. How do we know whether smokers are prompted to buy cigarettes by seeing packets of cigarettes, by the presence of the outlet itself, or both? Recent qualitative research in NSW goes some way towards answering this question. 74 Following the introduction of display bans in all stores except tobacconists, the study investigated whether the sight of tobacco retailers, tobacco shelving and signage created environmental cues to buy and/or smoke cigarettes among smokers and attempting quitters. 74 As well as being interviewed, subjects used a voice recorder and disposable camera to make recordings over a four-day period whenever they were tempted to smoke or buy cigarettes. Alcohol was the strongest environmental factor associated with smoking. 74 All participants but one provided unprompted comments that they were more likely to smoke at licensed premises, often more than they intended. 74 This was particularly the case for light smokers. 74 The sight of tobacco cupboards and signage was an environmental cue for some participants. 74 Seeing the outside of a tobacco retailer, particularly tobacconists and liquor stores, also triggered the urge to smoke among some subjects. 74 The results are preliminary and more research is needed, but this study provides the first evidence that the sight of tobacco retailers, even in the absence of point-of-sale displays, can prompt people to buy cigarettes and/or smoke. 74 It suggests the removal of point-of-sale display will reduce, but not completely eliminate, environmental cues and highlights the potential benefits of policies limiting the number and/or type of tobacco outlets. The researchers emphasised that any review of tobacco retailing should consider how licensed premises promote impulse purchases. 74 This study received funding from Cancer Council NSW. 8

11 Tobacco retailing in NSW The Ministry of Health states the purpose of tobacco legislation in NSW is to reduce the incidence of smoking and the consumption of tobacco and other smoking products (e.g. water pipes and herbal cigarettes), particularly by young people. 75 A display ban on tobacco products was enacted by the Public Health (Tobacco) Act 2008 (NSW) 1 hereafter referred to as the Act, which came into effect on 1 July Along with the Public Health (Tobacco) Regulation 2009, 76 it sets a number of conditions for the legal sale of tobacco and related products in NSW (see below). Key provisions of the Public Health (Tobacco) Act 2008 (NSW) 1,76 Sale of tobacco products to persons under the age of 18 years is prohibited, as is purchase on behalf of a person under 18. Tobacco retailers must notify the Ministry of Health before they engage in tobacco retailing. Tobacco products, non-tobacco smoking products and smoking accessories must not be visible to the public from inside or outside the premises. The display ban has been phased in over four years and small retailers and specialist tobacconists have had extra time to comply. At the time of the Cancer Council NSW audit of tobacco retailers, all retailers except specialist tobacconists were required to comply. As of July 2013, all retailers including specialist tobacconists should be fully compliant. Tobacco and related products may be sold only from one point of sale (i.e. cash register) on each premises. Vending machines can only be placed in an area of a hotel, club or casino restricted to over 18s, and only one vending machine per licensed premises is allowed. Vending machines must be controlled by staff members (e.g. by supplying tokens or remote control). Retailers must display a standard Smoking kills warning sign and a notice that it is illegal to sell tobacco products to persons under 18. Prices may be displayed either on price tickets or on a single price board, but not both. There are restrictions on the size and colour of price displays. Tobacco and related products cannot be included in shopper loyalty programs. Smokeless tobacco products, fruit-flavoured cigarettes and confectionary-flavoured cigarettes cannot be sold. Sales are not permitted from mobile or temporary retail outlets. Note: There is no law against people aged under 18 years selling cigarettes. See the glossary on the contents page for definitions of tobacco products, non tobacco smoking products and smoking accessories. Matches and lighters are not covered by the legislation and may be legally displayed. More information about tobacco retailing laws can be found at: tobacco/information_for_tobacco_retailers_ and_consumers.asp 9

12 Retailer Notification Scheme The Act requires tobacco retailers to notify the Ministry of Health before they engage in tobacco retailing. The set of arrangements for complying with this requirement is called the Retailer Notification Scheme. Businesses selling tobacco at the time the legislation was passed were also required to notify the Ministry of their retailing status. Notification is free, however specialist tobacconists paid a one-off fee of $250 to be listed as such and be granted extra time to comply with the new legislation. 77 Tobacco retailers must provide details of each retail premises via the NSW Government Licensing Service. 77 Details include the business name, business type (e.g. petrol station, newsagent, licensed premises), business address, trading address, Australian Business Number, and owners and directors names. Retailers are required to update their details if there is a change in the business address, trading address or business ownership. In the case of tobacco vending machines, both the owner of the machine and the lessee (e.g. the occupier of a pub or club where the machine is located) must notify the Ministry of their business details. 78 The Retailer Notification Scheme is described as a negative licensing scheme. 21 This means retailers do not need to obtain a licence or meet any defined requirements prior to selling tobacco, but can be prohibited from selling if they repeatedly breach the conditions of sale. If a retailer is convicted of two offences against the same provision of the legislation (such as failure to notify) on the same premises within a three-year period, they will be prohibited from selling tobacco for three months. Three offences on the same premises within three years incurs a 12 month prohibition. 75 The stated purpose of the Notification Scheme is to inform the Ministry of Health about the number and location of tobacco retailers in NSW, in order to support enforcement of the display ban and other retail laws. 77 Environmental Health Officers are able to check whether tobacco retailers have made a notification when they are undertaking routine checks on compliance with display and signage laws. 78 Selling tobacco without notification can incur an on-the-spot fine of $250 and a maximum penalty of $11, Monitoring, enforcement and compliance Effective enforcement of tobacco retailing laws is crucial if these laws are to successfully reduce smoking in the population. A recent systematic review of the effectiveness of sales to minors legislation, for example, found every intervention that had successfully disrupted the sale of tobacco to minors was associated with an observed reduction in tobacco use by youth. 80 Strategies that were not strong enough to effectively disrupt sales, or relied entirely on retailer education, did not reduce smoking on their own. 80 Cancer Council NSW has not identified any publicly available data about the number of compliance checks, violations, prosecutions or convictions of tobacco retailers under the Public Health (Tobacco) Act Published research from the NSW Central Coast in the 1990s found that where there was active enforcement of sales to minors legislation, along with retailer education and media publicity about prosecutions, there was increased retailer compliance and reduced youth smoking The most recent readily available state-wide data indicate compliance with sales to minors legislation of 84% in A newspaper report on the NSW North Coast indicated 81% compliance in Another news report said NSW Health had made around 1,000 inspections on 12,500 tobacco retailers in , 86 which if correct, means fewer than 10% of retailers were inspected during the year. 87% of smokers are within walking distance of a retail outlet, during their daily activities. 10

13 Cancer Council NSW audit of tobacco retailers Following the introduction of the Public Health (Tobacco) Act 2008, Cancer Council NSW has explored opportunities to support quit attempts, to reduce smoking rates in disadvantaged communities and to further reduce smoking uptake by young people. The available evidence shows that the number and location of retail outlets can influence smokers behaviour and different types of outlets affect different types of smokers. Reforms designed to differentially reduce purchases by young people and attempting quitters, as well as impulse purchases, would be attractive options to explore as they may increase the impact of tobacco control policy. The Retailer Notification Scheme presented an opportunity to better understand the structure, density and distribution of the tobacco retail sector as it provided a source of information about all retailers in NSW. Cancer Council NSW obtained the list of retailers that had notified with the Retailer Notification Scheme under a Government Information (Public Access) request (formerly Freedom of Information), since the list is not publicly available. Release was granted on the basis of overriding public interest in disclosure of the information, and because the information was already publicly available although not in a consolidated source. Cancer Council NSW received the list of notified retailers as a spreadsheet, with data fields including the registered business name, ACN, type of business, trading address and in some cases, the trading name of the business. The first data set of 12,451 records was received in April Cancer Council NSW made a second request for updated data in 2012 and received two additional data sets. Together, the three files comprised 13,439 records and covered retailer notifications up to 30 June What we wanted to find out Our objective was to conduct an audit of a sample of tobacco retailers. We wanted to assess the potential of the Retailer Notification Scheme data as a research resource, and to determine whether the data adequately captured the number and location of retailers in NSW for use in monitoring compliance with retail legislation. The audit aimed to discover if there were retailers that have not notified under the Retailer Notification Scheme, and to assess retailer compliance with the point-of-sale display ban and other in-store provisions of the Public Health (Tobacco) Act We also wanted to measure variations between retailers in the price of one popular brand of cigarettes, to obtain data on the entry and/or exit of tobacco retailers from the market, Figure 1: Location of postcodes selected for survey Penrith Coffs Harbour Liverpool Sydney Tamworth Dubbo Newcastle Sydney 11

14 and to investigate whether there were differences in compliance by retail outlets in urban compared to regional areas, more disadvantaged compared to less disadvantaged areas, and areas with higher compared to lower proportions of children in the population. It was expected that data collectors would have more success finding unlisted retailers in an area familiar to them. Therefore, if they were assigned to audit a randomly selected postcode that was not their home (residential) postcode, data collectors were also asked to look for unlisted retailers in their home postcode. What we did Preliminary examination of the 13,439 retailer records provided by the Ministry of Health revealed that some records were incomplete, incorrect, or could not be matched to a street address. We reviewed those that were obviously incorrect (e.g. where the postcode did not match the suburb), recorded errors and corrected them where possible. There were many cases of multiple records for the same premises and after excluding records that exactly matched the business name and address in another record, 12,731 tobacco retailers remained in 605 postcodes. Audit area Cancer Council NSW has a network of regional offices, eight of which took part in the study. These regions covered 468 postcodes containing 10,794 retailer records, or 77.4% of the postcodes and 80.3% of the notified retailer records represented on the Ministry of Health list. To select a sample of tobacco retailers, we randomly selected postcodes within each region until we reached pre-defined sampling targets. 87 Through this process, 100 postcodes were randomly selected. Five of those postcodes were very small rural localities in which no data collectors could be recruited, resulting in a sample of 2,279 retailer records in 95 postcodes. Of these, 51 were in regional NSW and 44 were in the Sydney metropolitan area (Figure 1). The sample records included 61 recorded address errors, which included incorrect postcode (24), missing street name and/or number (21) and incorrect suburb (8). Survey and data collection We developed a survey to record observations of key features of the in-store environment (including products on display, presence or absence of a Smoking kills warning sign and features of price boards or price tickets) and to record the price of a standard brand of tobacco (Winfield 25 pack and 50 pack). Data were collected in each Cancer Council NSW region by 166 staff and volunteers who had received either face-to-face or telephone training. The audit took place between November 2012 and early February 2013, with most data collected in November and December Data collectors received survey forms for all notified retailers in their allocated postcode or neighbourhood, a summary list of notified retailers in their area, and maps. Each data collector was asked to audit approximately 20 notified ( listed ) retailers within one of the randomly selected postcodes, and to look for any tobacco retailers in their area that did not appear on their summary list ( unlisted retailers). If any unlisted retailers were found, they performed the same audit as for listed retailers. What we found All unlisted tobacco retailers identified by data collectors were reviewed against the original list of notified retailers provided by the Ministry of Health and against an updated list that included notifications during the period of the study. After this process, 174 retailers in 79 postcodes were categorised as unlisted and added to the audit data. There was an average of 17.7** active tobacco outlets (i.e. outlets currently selling tobacco) per postcode. Postcode 2010 (Darlinghurst/Surry Hills) had the highest number, with 107 active outlets. Within the 17 remote and outer regional postcodes in our selected sample, there was an average of 7.3 active tobacco outlets per postcode. Almost 80% of outlets are convenience, route and impulse retailers Together, convenience, route and impulse retailers (i.e. licensed premises, convenience stores, petrol stations and newsagents) represented 78.3% of tobacco outlets. By contrast supermarkets and tobacconists dominate market share. 88 Outlets in licensed venues were the most numerous, representing 34.2% of our sample (Figure 2). Figure 2: Proportion of each type of outlet in survey sample Licensed premises^ Convenience store Convenience, route and impulse retailers = 78.3% Petrol/service station Newsagent Supermarket % of all surveyed outlets^^ Tobacconist General grocery store Other/Not specified ^ Includes vending machines and over-the-counter sales in pubs, clubs, hotels, bars, bottle shops and licensed restaurants. ^^Surveys were completed for 1,739 retailers, comprising 1,565 listed retailers and 174 unlisted retailers. Of the 2,279 listed records sampled, 664 were multiple listings or retailers no longer selling tobacco and 50 were not surveyed. This is a summary of our findings. Further results are available in a separate report. 87 **Standard deviation Standard deviation

15 The Retailer Notification Scheme does not provide accurate information about tobacco retailers in NSW The audit showed the Retailer Notification Scheme does not accurately record the number, type and location of tobacco retailers in NSW. It found there are retailers not included in the list of notified retailers provided by the Ministry of Health. In addition, the list of notified retailers includes a large number of multiple listings and out-of-date retailer records. Multiple listings for the same business may mean businesses are not notifying changes to business location or ownership, or notifications of changes are not reflected in Ministry of Health records. We estimate that there is one unlisted tobacco outlet for about every 13 listed outlets To estimate the ratio of unlisted to listed outlets, we compared the number of unlisted to listed retailers in randomly selected postcodes where at least one of the data collectors lived in the postcode. 87 In this subset of postcodes, 109 unlisted outlets were identified in addition to 1,369 listed outlets, resulting in a ratio of one unlisted outlet for every listed outlets. It is unlikely data collectors located every unlisted retailer, so this figure is probably an underestimate. The likelihood of being unlisted varied between different types of outlets. General grocery stores had the highest proportion of unlisted outlets (34.8%), while convenience stores and tobacconists had the lowest (6.1 and 6.2% respectively; Figure 3). Outlets in major cities were more likely to be unlisted than those outside major cities. Figure 3: Proportions of unlisted outlets and outlets with one or more breaches, by type of outlet We estimate that NSW has approximately 9,597 tobacco outlets The Retailer Notification Scheme does not accurately quantify the number of tobacco retailers in NSW because it includes a large number of multiple listings and excludes unlisted outlets. However, we can estimate the total number by using the audit results. Of the 2,229 listings checked during our survey (2,279 records less 50 not visited ), 664 were multiple listings or retailers no longer selling tobacco. Applying the proportion of listings found to be active outlets (1,565/2,229=70.2%) to the number of records listed under the Scheme after exact duplicates were removed (12,731 as at 30 June 2012), and adding an estimate of unlisted retailers based on the ratio described above, the result is an estimate of 9,597 tobacco retail outlets in NSW. 87 One in four tobacco retailers did not comply with the legislation More than one in four audited tobacco retailers (26.6%, Table 1) did not comply with the requirements of the Act, either because they had not notified under the Retailer Notification Scheme (according to Ministry of Health records) or because they failed to comply with in-store requirements, or both. The most commonly observed breach was failure to display a Smoking kills warning sign (11.9% of retailers, Table 1). Tobacco products were on display in 5.5% of retailers and smoking accessories or non-tobacco smoking products were displayed in 3.6% of retailers. (These figures do not include specialist tobacconists, which could still legally display tobacco and related products at the time of the survey.) Results regarding the two types of breaches involving exact measurements should be interpreted with caution. The Public Health (Tobacco) Regulation states price lettering must be no more than 2 cm high and/or 1.5 cm wide. Also, any tobacco display in a specialist tobacconist must be more than 2 m away from any public facing opening. Data collectors estimated rather than measured these distances so these data may not be entirely accurate Licensed premises Convenience store Petrol/service station Newsagent Supermarket Tobacconist General grocery store Other/Not specified % unlisted^^ % with one or more in-store breaches^^ ^^Total of 1,739 listed and unlisted outlets. Data collectors did not audit 50 retailers in selected postcodes (3.1% of active outlets) because they were closed at the time of visit or due to lack of time. Of these 664 records, some were legitimate dual listings for vending machines: NSW legislation requires notification by both the vending machine operator and the licensee. While correctly reflecting the legislation, such dual listings, if unaccounted for, inflate the actual number of tobacco outlets in NSW. 13

16 Table 1: Observed breaches of tobacco retail legislation Type of breach Number (%) of outlets No Smoking kills sign 201 (11.9) Outlet selling tobacco but not listed with Ministry of Health 120 (6.9) Displaying tobacco but not a specialist tobacconist 93 (5.5) Displaying smoking accessories or non-tobacco smoking products but not a specialist tobacconist 60 (3.6) More than one type of price display 22 (1.3) Prices more than 2 cm high and/or 1.5 cm wide 18 (1.1) Outlet advertising or promoting cigarettes 14 (0.8) Specialist tobacconist displaying tobacco less than 2 m away from a public facing opening Non-compliant warning sign colour (identified from volunteer comments) 14 (0.8) 1 (0.1) Outlets with one or more observed breaches 448 (26.6) Total breaches observed ^Some outlets had more than one breach. % = percentage of 1,685 listed and unlisted outlets surveyed in randomly selected postcodes. n=543^ Unlisted retailers and those in disadvantaged areas were more likely to break retailing laws Retailers not listed under the Retailer Notification Scheme were significantly more likely than listed retailers to breach in-store provisions of the legislation, even after adjusting for other factors. Among unlisted outlets, 36.8% recorded a breach, compared to 21.0% of listed retailers. Retailers in disadvantaged postcodes were significantly more likely to breach in-store provisions of the legislation than those in less disadvantaged postcodes. Again, this relationship held after adjusting for other factors. Breaches were more likely in certain types of outlets. In the survey, tobacconists were observed to have the highest proportion of breaches of in-store provisions, but the most common breaches were price lettering more than 2 cm high and or 1.5 cm wide, and display less than 2 m away from any public facing opening. This finding should be interpreted cautiously for the reasons noted previously. General grocery stores, convenience stores and other/unspecified types of outlets also had relatively high proportions of outlets with one or more breaches (Figure 3). Petrol stations scored lowest, with 15.5% of petrol stations having one or more breaches of in-store provisions. Cigarettes were cheaper in areas with more young people and in disadvantaged areas The average price for a pack of Winfield 25s in audited outlets was $ Prices varied significantly between different types of outlets with tobacconists and supermarkets the cheapest, at $16.09 and $16.51 respectively. Convenience stores, petrol stations and licensed premises were all significantly more expensive than supermarkets. Licensed premises (including pubs, clubs, bars and bottle shops) had the highest average pack price at $18.83 (Figure 4). After taking into account the type of outlet and other factors affecting prices, we found a significant trend for lower prices in postcodes with a higher proportion of young people (aged under 18) in the population. Prices also varied according to the level of disadvantage in the postcode, with the lowest average price ($17.40 per 25 pack) in the most disadvantaged postcodes. The relationship remained significant, but was not linear, after adjusting for other factors. Unexpectedly, prices were not significantly different in regional and remote areas compared to major cities. Prices were slightly (but not significantly) lower in regional and remote areas, even after taking into account the type of outlet and other factors. Figure 4: Cigarette prices All outlets Licensed premises^ Petrol station Convenience store General grocery store Newsagent Supermaket Average price per 25-pack ($)^^ Tobacconist Other/Not specified ^Includes vending machines and over-the-counter sales in pubs, clubs, hotels, bars, bottle shops and licensed restaurants. ^^Sample of 1,579 listed and unlisted outlets with information on price. Some tobacco retailers are leaving the market The audit results indicated 418 of the 2,279 notified retailer records were either no longer selling tobacco or no longer at the stated address. However, it was not possible to quantify the number of retailers that had entered or exited the market over the three years the Retailer Notification Scheme has been in place. The list of retailer records provided to Cancer Council NSW by the Ministry of Health was a cumulative list and did not record entry or exit dates. Therefore, we could not determine whether the total number of tobacco retailers is increasing or decreasing over time. 14

17 What we learned The Cancer Council NSW audit of tobacco retailers provides new and unique information about tobacco retailing in NSW. Thanks to the Government Information (Public Access) Act and the efforts of 166 staff and volunteer data collectors, we are able to provide the first publicly available data regarding retailer compliance with key features of the Public Health (Tobacco) Act We also gathered new data regarding cigarette prices. The study had some limitations which should be noted. It did not include most of western NSW and the large number of data collectors may have led to some inconsistencies in observation. Cancer Council NSW would welcome the release of any Ministry of Health tobacco retailer compliance data and monitoring procedures for comparison. The high average number of tobacco outlets per postcode (17.7 across all postcodes in the sample and 7.3 in outer regional and remote postcodes) suggests there is scope to reduce the number of outlets without making it unreasonably difficult to buy cigarettes. Almost four out of five outlets are convenience, route and impulse retailers, so the current level of retail density is of little utility to entrenched smokers, who tend to make planned purchases in lower-cost outlets. Compliance must improve Many retailers are not meeting the full range of requirements of the Act. Though compliance with the point-of-sale display ban was reasonably high, the audit found 26.6% of retailers failed to comply with one or more provisions of the legislation. This is almost certainly an underestimate as: there was no attempt to monitor compliance with all provisions of the legislation; it was not possible to check whether the listed business name was up-to-date; and incomplete or invalid addresses were not counted in the measure of non-compliance, though the Retailer Notification Scheme requires retailers to give the address of the premises where retailing occurs. 1,77 Our estimate of one unlisted retailer for every 13 listed retailers is also likely to be an underestimate as data collectors are likely to have missed some unlisted retailers. Retailers that had failed to notify (i.e. those hardest for enforcement officers to find) were significantly more likely than notified retailers to breach in-store retail laws. Also, retailers in disadvantaged postcodes were less likely to comply with these laws than those in less disadvantaged postcodes. As people in disadvantaged communities are more likely to be smokers 10 and find it harder to quit, 90 the results suggest those at most risk of tobacco-related harm are afforded the least protection by the current laws. Prices vary between areas It is well established that lower prices are associated with increased tobacco consumption. 91 The finding that cigarette prices were lower in disadvantaged areas and in areas with a higher proportion of young people makes sense from a business point of view, as these are neighbourhoods where customers have less capacity to pay. However, from a tobacco control point of view, it means communities at higher risk of harm from tobacco are exposed to the least protective retail environment. Prices were highest in the types of outlets more often used by lighter smokers and impulse purchasers, such as bars, pubs, clubs, bottle shops, petrol stations and convenience stores. In these types of outlets, where smokers trade off price for convenience, high prices may be less of a barrier to purchase than in other types of outlets. Reducing access to cigarettes by restricting retail supply may create an additional barrier in impulse-prone environments, thereby helping tipping point smokers to resist purchase. A stronger notification system is needed The Retailer Notification Scheme does not appear to meet its stated objective, which is to inform the Ministry of Health about the number and location of tobacco retailers in NSW in order to support enforcement of the tobacco retailing requirements in the Public Health (Tobacco) Act ,77 The notification data contained invalid addresses, out-of-date records and many cases of multiple listings for a single outlet. In one case there were four listings under different business names at the same address, presumably due to repeated turnover of the business and notification by each new owner without removing or inactivating notifications by the previous owner. In addition, we found a substantial number of retailers selling tobacco that did not appear in the list of notified outlets. In the absence of publicly available information about monitoring and enforcement activities, it is not possible to assess whether Environmental Health Officers have access to other, better quality retailer data. Even if they do, observed levels of non compliance indicate a stronger system is needed to enforce retailing laws and reduce tobacco use in NSW. A positive licensing scheme with a requirement for annual renewal and an associated licence fee, for example, would help boost compliance by providing resources for enforcement and communication. An annual licence renewal fee would also help keep the retailer list up to date as retailers would then have a financial incentive to notify if they stop selling tobacco products. If the integrity of NSW tobacco retailer data is not improved, it will become more and more inaccurate over time. The NSW Government has a responsibility under the National Tobacco Strategy to consider further options for licensing schemes and to commission research to examine approaches for placing controls on the number and type of tobacco outlets. Any action to ensure the reliability of notification data will make it easier to carry out that work, as well as to conduct enforcement and retailer education. 15

18 The case for tobacco retail reform The NSW and Australian Governments have banned tobacco advertising, promoted anti-smoking messages through health warnings and plain packaging, increased tobacco prices to reduce demand, regulated to stop children buying tobacco and introduced smoke-free public places and workplaces. However, NSW still has close to 10,000 places to buy cigarettes. Public health experts have proposed a number of supply-related strategies to further decrease smoking and its associated health costs, including: limiting the number of tobacco outlets; 92 restricting tobacco sales to certain types of outlets; 92 introducing a smoker licensing scheme, whereby smokers would need a smart swipe-card licence to purchase tobacco products from a licensed retailer; 93 banning tobacco sales to anybody born after a certain year (i.e. young people); 92 mandated limits to supply; 92 nationalisation of the tobacco industry; 92 and making tobacco products illegal. 94 Cancer Council NSW believes the most feasible approach is incremental, starting with stronger tobacco retail regulation. The immediate benefit of stronger regulation is that it would further reposition tobacco as the harmful product that it is, and contribute to denormalisation of smoking and tobacco products. The challenge is to identify policies that will maximise public health benefits by supporting smokers to quit and remain quit, preventing youth uptake, and reducing the disparity in smoking rates between disadvantaged communities and the general population. What does the evidence suggest? There is emerging evidence that retail cues to smoking persist, even in the absence of point-of-sale displays. It is not just children who are affected by the retail availability of tobacco. The majority of smokers want to quit, but quitting is difficult, 95 and while overall smoking prevalence has declined steadily in NSW and in Australia, state 96 and national 97 data show the percentage of people identifying as ex-smokers has stabilised. This suggests the rate of quitting has slowed and the decline in prevalence is now largely attributable to reduced uptake. Tobacco retail policies that are aligned to support quit attempts would therefore be appropriate and well-targeted. Research suggests the ubiquity of tobacco retail outlets presents a barrier to quitting. 15,58,59 Convenience stores, service stations and licensed outlets, for example, are more likely to be the site of impulse and relapse purchasing. 15,31 Living close to a tobacco retailer also reduces the chance of quitting successfully. 58 Generally reducing retail density will reduce tobacco use. However, strategically reducing convenience, route and impulse retailers may accelerate tobacco control by discouraging purchase by attempting quitters and lighter smokers as they are less likely to have a stock of cigarettes on hand. They may also be at the tipping point of susceptibility to point-of-purchase cues to smoke. 61 Any measure to eliminate tobacco sales at licensed outlets is likely to lessen the role of alcohol in tobacco consumption. Drinking alcohol, especially in social settings like bars and clubs, increases the amount of smoking, increases the likelihood of non-daily smokers smoking and undermines quit attempts. 15,62-64 Tobacco outlets where alcohol is sold account for a small percentage of cigarette purchases, 98 and the tobacco industry s persistent expenditure of effort on these outlets suggests a deliberate attempt to recruit new smokers and exploit tipping point smokers for impulse and relapse purchases. Higher prices in these outlets appear to be insufficient to discourage purchase. Retail reform may help address disparities in smoking rates and reduce health inequities. There is a higher density of tobacco retail outlets in disadvantaged local government areas of NSW after adjusting for smoking prevalence, 52 and our audit has found compliance with retail legislation is lower in more disadvantaged postcodes. This suggests the retail environment is more smokogenic for disadvantaged people, who already have higher smoking rates and poorer health than the general population. They also find it harder to quit smoking. 90 To prevent young people taking up smoking, retailer compliance with laws banning sales to under-18s is crucial. 80 Research on sales to minors also shows effective compliance requires ongoing monitoring and enforcement, not just retailer education. 80 Our audit did not assess compliance with sales to minors legislation, but found room for improvement in compliance with other provisions, such as notification and signage requirements. We also found cigarettes were significantly cheaper in areas with higher proportions of children in the population, which is a cause for concern. Retail reforms limiting young people s exposure to outlets selling cigarettes, such as excluding tobacco retailers in proximity to schools and other youth facilities, could be a valuable adjunct to enforcement of bans on sales to minors. No single measure will be effective in addressing the tobacco epidemic and successful tobacco control comprises a portfolio of measures that contribute to reducing uptake of smoking, promoting quitting and reducing relapse after quitting. There is enormous potential for tobacco retail reform to help the government achieve its targets for further reducing smoking. However, restructure of the retail sector requires an active retail regulatory regime. A positive licensing system could be innovatively designed to discourage purchase by young and tipping point smokers and to improve compliance with existing legislation. Strategic research and stakeholder engagement is needed to inform decisions about the most effective model of retail reform. 16

19 Regulation of other products In NSW, there are many precedents for licensing systems for businesses that supply goods or services entailing varying degrees of risk. Alcohol Liquor licensing places limits on where, when and to whom alcohol may be sold. Community and social factors are considered during the application process. Applicants for a liquor licence in NSW must include a National Police Certificate, a community impact statement, a scaled plan of the proposed licensed premises and a copy of the local council s development consent or approval for the proposed premises. 99 The licensee, service staff and security officers must hold Responsible Service of Alcohol certificates. 100 Licence fees vary depending on the type of outlet (e.g. for a restaurant or small bar the application fee is $500). 101 Once a licence is approved, licensees are subject to a three strikes scheme whereby non-adherence to sale and supply laws may result in the licence being subject to conditions, suspended for up to 12 months, or cancelled. A licensee can also be disqualified for any period of time. Additionally, all licensees are required to report back to the licensing authority biennially in order to confirm the accuracy and currency of the database. 102 Prescription medicines To sell scheduled medicines in Australia, pharmacists must hold a pharmacy degree. They must maintain their registration or face severe penalties which include the loss of registration and criminal prosecution if found to be selling some medicines without being presented with a valid doctor s prescription. 103 Equally, when a person is prescribed a medicine, the prescription specifies the pharmacist can only release a limited supply. Patients requiring more must return to a doctor for a repeat prescription. This stands in stark contrast to tobacco a product with no safe level of use which any person can sell to any other person aged 18 or over. Registration of a new pharmacy business in NSW incurs a fee of $500, plus an additional $300 inspection fee. 104 Annual renewal of registration is $300. Registration of a change of address is $300 and a change of ownership is $ Second-hand goods All pawnbrokers in NSW must have a licence and second hand dealers must have a licence if they buy or sell certain goods, including musical instruments, sporting goods, photographic equipment, tool kits, mp3 players, computer equipment, microwave ovens and certain jewellery. 16 To be eligible, licensees must be considered fit and proper for the purposes of the licence and provide address details of the premises where goods will be sold. Licence details must be conspicuously displayed on the business premises. 105 The application fee is $473 while the renewal is $ Others Other businesses that must be licensed in NSW include: 106 businesses that handle or process certain foods, including meat, seafood, dairy products, eggs and sprouts; 107 tattoo parlours; 108 real estate agents; 109 motor dealers; 110 and travel agents

20 Public opinion There is strong public support for tighter regulation of tobacco retailers. In a recent Cancer Council NSW community-based survey, 2,473 adults were asked for their reaction to policies requiring retailers to have a licence to sell tobacco products in the same way retailers need a licence to sell alcohol. 112 Almost eight in 10 respondents (79%) strongly supported or supported the policy higher levels of support than for point-of-sale display bans and plain packaging, which are already in place. The results of the 2009 NSW Smoking and Health Survey also indicate that the community is ready for tobacco retailer licensing. Ninety-one per cent of adults supported such regulation, including 88% of smokers. 113 Given most smokers have made at least one quit attempt, 113,114 perhaps they are reflecting on the problem that retail availability poses to quit success. In another NSW population-based survey in 2004, 81% of respondents agreed tobacco products are too easy to buy. The same percentage supported phasing out vending machines in licensed premises to reduce access by minors, 73% supported reducing the number and type of tobacco outlets and 57% supported completely prohibiting tobacco within 10 years. 115 Innovative model of retail reform: California Tobacco licensing in California is regulated at the local government level. The Center for Tobacco Policy and Organizing, which is funded by the state government s California Tobacco Control Program, has examined the tobacco retail licensing ordinances of 94 communities across California. 116 It defines a strong licensing ordinance as one that: requires all retailers to hold a licence to sell tobacco products, which must be renewed annually; sets a licence fee high enough to sufficiently fund administration of the program and enforcement efforts; clearly states an enforcement plan that includes compliance checks; coordinates tobacco regulations so that a violation of any existing local, state or federal tobacco regulation violates the licence; and provides a financial deterrent through fines and penalties, including the suspension and revocation of the licence. 116 Beyond this, different communities have introduced a variety of provisions, such as restrictions on the type of retailer, limits on the location and density of retailers, prohibitions on smoking within and near the premises, and sales conditions. Examples of such provisions are (note that different provisions apply in different places): 116 a licence may not be granted to any business offering food or alcoholic beverages for sale for consumption on the premises; a licence may not be granted to new businesses that are significant tobacco retailers (i.e. retailers for which the principal or core business is selling tobacco products, tobacco paraphernalia, or both [exempting existing retailers]); the total number of licences is restricted to one per 1,000 residents (exempting existing retailers); a licence may not be granted in any location exclusively zoned for residential use; a licence may not be granted to any retailer located within 500 feet of a youth-populated area, such as a school, park, playground, childcare facility, recreation facility or youth centre (exempting existing retailers); a licence may not be granted to any retailer within a certain distance of another tobacco retailer (200 feet or 500 feet, depending on the jurisdiction and exempting existing retailers); people selling tobacco must be of the minimum legal age to purchase tobacco products (18 years); smoking is prohibited inside retail premises and within 20 feet of any entrance, exit or window to the store; all licence applicants must verify that they have attended an approved training program on the laws relating to the sale of tobacco products; and the frequency of compliance checks is stated, with some communities making up to four compliance checks on each retailer per year. Licence fees in California range from a nominal US$30 to a high of US$655 annually. 18

21 Retailer opinion Research analysing tobacco industry documents has highlighted the importance of the retailer s role in communicating industry messages to consumers. 117 The industry knows that small, local retailers are an acceptable face for pro-tobacco lobbying, and has leveraged this relationship in its campaign against plain packaging reforms. 118 There is emerging evidence, however, that retailers are not always comfortable selling tobacco. 119 Some retailers interviewed for a small qualitative study in New Zealand revealed that selling tobacco was something they disliked, but felt they had to do because everyone else did. 119 The majority of these same retailers supported the concept of tobacco retailer licensing. They compared it to alcohol and felt it should be treated in a similar manner, though were understandably wary that a licensing system would be costly and complicated. The interviewees also supported tobacco retailers playing a role in providing cessation materials to customers, including being required to sell nicotine replacement therapies. 119 Interviews with Californian grocery store managers who had stopped selling tobacco revealed there were opportunities for businesses if they were no longer tobacco retailers. 120 Store managers saw the decision to end tobacco sales as image enhancing and consistent with being positioned as selling healthy foods. Focus groups with store customers showed that while they were largely unaware these retailers had stopped selling tobacco, they all supported the decision and said it made them more likely to shop there. 120 Research with retail businesses in NSW would be useful to explore the diversity of retailer opinions and business needs. A model for reducing the number of tobacco retailers over time: New York As in California, tobacco retailer licensing in the state of New York is a local government responsibility. Researchers at the Center for Public Health and Tobacco Policy have developed a model ordinance for tobacco retailing that includes a detailed strategy for slowly rolling back the total number of tobacco retailers by restricting licence availability. 121 The work was funded by a grant from the New York State Department of Health. The model ordinance is yet to be fully implemented, but proposes that: 121 For the first year of the licensing scheme, only those retailers who had registered as tobacco sellers at least six months prior to the launch of the scheme will be granted a licence; Following the first year, the number of licences issued will not exceed that of the previous year; and Following the first year, only one new licence will be issued for every two revoked or lapsed in the previous year. If the number of applications exceeds the maximum number of licences that may be issued according to the conditions above, then applications will be prioritised as follows: 121 First, licences will be granted to those who previously held a licence and are located a minimum distance from a school, where the distance is agreed upon by the local authority. If this still results in an excess of applications, then a lottery system is suggested; Second, licences will be granted only to those who sell from an adult-only facility. Again, if there are still more applicants than licences, a lottery system is suggested; and Third, if there are any remaining licences, these shall be distributed by a lottery system. 19

22 Conclusion Retail availability is the weak link in tobacco control. Selling tobacco anywhere, anytime thwarts people s attempts to give up this powerfully addictive substance and makes it harder for the government to reduce smoking prevalence which is still unacceptably high. It is simply not helpful for a substance that kills half its long-term users to be easier to buy than a postage stamp. Supply-side measures have tremendous potential to further denormalise tobacco and reduce use. Developing a policy and research strategy will require partnerships across government and non-government organisations. Cancer Council NSW recommends, as the first step, that the NSW Minister for Health establish a Ministerial taskforce to explore, evaluate and advise on policies for tobacco retail reform that will most effectively accelerate declines in smoking prevalence. A successful precedent for this approach is the NSW Passive Smoking Taskforce, which was established by the (then) NSW Department of Health in March It was convened to advise the Department on options for eliminating exposure to environmental tobacco smoke in places where food and beverages are consumed, and prepare a report for the Minister for Health. Cancer Council NSW believes a taskforce would be valuable in developing innovative, evidence-informed policies for tobacco retail reform. Its purpose would be to create a retail environment that supports, rather than counters, other tobacco control initiatives. In the meantime, there is also a clear need to improve compliance with existing laws and to ensure the integrity of retailer data collected under the Retailer Notification Scheme. A publicly accessible, searchable list of notified tobacco retailers in NSW should be available through the Government Licensing Scheme website. Similar online lists already exist for many licensed and registered businesses, professions and tradespeople. 106 This would make it easier for community members to report a possible breach of the legislation and facilitate research by non-government and academic organisations. Finally, publicly available data are needed on monitoring and enforcement of tobacco retailers, including the proportion of tobacco retailers receiving compliance checks each year, compliance rates, prosecutions and convictions. Tobacco control is vitally important to the community, both ethically and economically, and greater transparency would promote collaboration and public engagement. Membership included government representatives, health groups, stakeholders from the hotels, clubs and restaurant industries, and WorkCover NSW. Independent experts were also commissioned to examine scientific issues and possible approaches. The Taskforce conducted public consultations to canvass community views. It released its report in 1997, recommending the introduction of legislation to ban smoking in indoor places where food and drink are consumed. The legislation came into effect in the year

23 Recommendations Addressing the retail availability of tobacco in NSW could accelerate declines in smoking prevalence, support people more effectively to quit smoking, promote health in socially disadvantaged areas and protect children from tobacco. A taskforce for tobacco retail reform Cancer Council NSW recommends the NSW Minister for Health: 1. Convene a taskforce under the auspices of the Minister s office to explore, evaluate and advise on policies for tobacco retail reform that will most effectively accelerate declines in smoking prevalence. 2. Require the taskforce to base their advice to the Minister on the best available evidence. 3. Include the following responsibilities among the taskforce s terms of reference: commission research to more closely assess the impact of retail distribution on smoking in the NSW context; consult with the public and affected retail sub-sectors; assess the potential for a positive licensing scheme, with associated conditions of licence and an annual fee, as a means to boost resources for monitoring and enforcement; develop strategies to restrict the number, type and distribution of retail outlets; and outline the essential elements of a regulatory scheme that would effectively address the impact of tobacco retail availability on smoking rates. 4. Appoint a maximum of nine members to the taskforce, including the chair, with expertise in: tobacco control (one or two members); public health, particularly preventive health in Aboriginal and disadvantaged communities (one or two members); public health law and regulation (one member); academic retail marketing research relevant to the terms of reference (one member); and the retail sector (maximum of three members, chosen to reflect the diversity of the retail market). 5. Exclude from taskforce membership (but include in consultations) individuals and/or organisations that receive funding from tobacco companies or are directly affiliated with those companies. 6. Request the taskforce to report their findings within one year of being convened. Strengthening compliance with existing tobacco retail laws Cancer Council NSW recommends the NSW Ministry of Health: 7. Introduce systems to ensure notifications under the Retailer Notification Scheme are accurately collected and recorded, so as to provide up-to-date information about outlet address, changes in business ownership and whether the outlet continues to sell tobacco. 8. Provide a publicly accessible, searchable online database of all notified tobacco retailers in NSW. 9. Provide publicly accessible annual reports with quantitative measures of retailer monitoring, compliance, prosecutions and convictions for each Local Health District. 21

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28 153 Dowling Street Woolloomooloo NSW 2011 cancercouncil.com.au facebook.com/cancercouncilnsw twitter.com/cancercouncil or #cancercouncil to show us yours linkedin.com/company/cancer-council-nsw pinterest.com/cancercouncil