Facts & Issues. Tobacco in Australia. A comprehensive online resource. tobaccoinaustralia.org.au

Transcription

1 Tobacco in Australia A comprehensive online resource Facts & Issues tobaccoinaustralia.org.au

2 Book excerpt List of chapters available at tobaccoinaustralia.org.au Introduction Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 9 Trends in the prevalence of smoking Trends in tobacco consumption The health effects of active smoking The health effects of secondhand smoke Factors influencing the uptake and prevention of smoking Addiction Smoking cessation Tobacco use among Aboriginal peoples and Torres Strait Islanders Smoking and social disadvantage Chapter 10 The tobacco industry in Australian society Chapter 11 Tobacco advertising and promotion Chapter 12 The construction and labelling of Australian cigarettes Chapter 13 The pricing and taxation of tobacco products in Australia Chapter 14 Social marketing and public education campaigns Chapter 15 Smokefree environments Chapter 16 Tobacco litigation in Australia Chapter 17 The economics of tobacco control Chapter 18 The WHO Framework Convention on Tobacco Control Appendix 1 Useful weblinks to tobacco resources Tobacco in Australia: Facts and Issues. Third Edition A comprehensive review of the major issues in smoking and health in Australia, compiled by Cancer Council Victoria. First edition published by ASH (Australia) Limited, Surry Hills, NSW, 1989 Second edition published by the Victorian Smoking and Health Program, Carlton South, Victoria (Quit Victoria), 1995 Third edition published by Cancer Council Victoria 2008 in electronic format only. ISBN number: Suggested citation: Scollo, MM, Winstanley, MH [editors]. Tobacco in Australia: Facts and Issues. Third Edition. Melbourne: Cancer Council Victoria; Available from: Tobacco in Australia: Facts and Issues; 3rd Edition updates earlier editions of the book published in 1995 and This edition is greatly expanded, comprising chapters written and reviewed by authors with expertise in each subject area. Tobacco in Australia: Facts and Issues is available online, free of charge. A hard copy version of this publication has not been produced. This work has been produced with the objective of bringing about a reduction in death and disease caused by tobacco use. Much of it has been derived from other published sources and these should be quoted where appropriate. The text may be freely reproduced and figures and graphs (except where reproduced from other sources) may be used, giving appropriate acknowledgement to Cancer Council Victoria. Editors and authors of this work have tried to ensure that the text is free from errors or inconsistencies. However in a resource of this size it is probable that some irregularities remain. Please notify Cancer Council Victoria if you become aware of matters in the text that require correction. Editorial views expressed in Tobacco in Australia: Facts and Issues. Third Edition are those of the authors. The update of this publication was funded by the Australian Government Department of Health and Ageing. Cancer Council Victoria 1 Rathdowne Street Carlton VIC 3053 Project manager: Kylie Lindorff, Policy Manager, Quit Victoria and VicHealth Centre for Tobacco Control Website design: Creative Services, Cancer Council Victoria Design and production: Jean Anselmi Communications

3 Tobacco in Australia Facts & Issues A comprehensive online resource tobaccoinaustralia.org.au Chapter 1 Trends in the prevalence of smoking

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5 Chapter 1: Trends in the prevalence of smoking 1 Chapter 1 Trends in the prevalence of smoking Table of contents Margaret Winstanley Dr Vicki White 1.1 A brief history of tobacco smoking in Australia Overview of major Australian data sets Prevalence of smoking adults Prevalence of smoking young adults Prevalence of smoking middle-aged and older adults Prevalence of smoking secondary students Trends in the prevalence of smoking by socioeconomic status Smoking and educational level Smoking and occupation Trends in prevalence of smoking by country of birth Prevalence of tobacco use among Aboriginal peoples and Torres Strait Islanders Prevalence of smoking in other high risk sub-groups of the population Smoking in pregnancy Smoking and mental illness Lone parents The homeless The prison population Other drug use... 19

6 2 Tobacco in Australia: Facts and Issues 1.11 Prevalence of use of different types of tobacco product Manufactured cigarettes, roll-your-own (RYO) cigarettes, pipes and cigars Unbranded loose tobacco ( chop-chop ) Smokeless tobacco products Future smoking rates? International comparisons of prevalence of smoking International comparisons of adult smoking prevalence International comparisons of smoking prevalence in children... 24

7 Tables and figures Chapter 1: Trends in the prevalence of smoking 3 Table 1.1 Percentage of current smokers in Australia, Table 1.2 Prevalence of current smokers in Australia aged 18+, Figure 1.1 Prevalence of current smokers in Australia aged 18+, Figure 1.2 Prevalence of current smokers in Australia aged 18+, males and females...8 Table 1.3 Table 1.4 Young adults percentage of current smokers by age group, sex and total population for age group, Middle-aged and older adults percentage of current smokers by age group, sex and total population for age group, Figure 1.3 Prevalence of current smokers in Australia aged 18+, by age group...10 Figure 1.4 Table 1.5 Table 1.6 Table 1.7 Prevalence of Australian secondary school students who report smoking in last week, Australia year-olds and 16- and-17-year-olds...11 Percentage of Australian secondary students who smoked in the last week, Prevalence of current smoking among Australian adults by educational level and sex, Prevalence of current smoking by occupational group and sex, Figure 1.5 Prevalence of current smokers in Australia aged 18+, 1980 to 2004 by occupational status...14 Table 1.8 Table 1.9 Table 1.10 Smoking among persons aged 18 years and over, by country of birth, period of arrival in Australia, and main language spoken in the home, Percentage of current daily smoking among Aboriginal peoples and Torres Strait Islanders by sex and age group, Women who smoked during pregnancy by Australian state and territory,

8 4 Tobacco in Australia: Facts and Issues Table 1.11 Table 1.12 Table 1.13 Figure 1.6 Table 1.14 Table 1.15 Table 1.16 Recent use of other drugs by smokers and non-smokers: proportion of the population aged 14+ by sex, Australia, Prevalence of smoking by type of tobacco used, Australian smokers by sex aged 18+, (data not weighted)...20 Type of tobacco smoked, smokers aged 18 years and over, Australia, 2001 and 2004 (data not weighted)...20 Four stages of the tobacco epidemic...23 Prevalence of daily smoking among population aged 15+ in OECD countries...24 Prevalence of smoking among adults in selected other countries...25 Current use of any tobacco product among school students aged by sex and World Health Organization region,

9 Chapter 1: Trends in the prevalence of smoking 5 Trends in the prevalence of smoking 1.1 A brief history of tobacco smoking in Australia Tobacco smoking first reached Australian shores when it was introduced to northerndwelling Indigenous communities by visiting Indonesian fishermen in the early 1700s. 1 British patterns of tobacco use were transported to Australia along with the new settlers in Among free settlers, officers and convicts, tobacco smoking was widespread 2, 3 and in the years following colonisation, British smoking behaviour was rapidly adopted by Indigenous people as well. *4 In the earliest days of the colony the tobacco supply was unreliable and usage among convicts, in particular, was restricted, 4 but by the early 1800s tobacco was an essential commodity routinely issued to servants, prisoners and ticket-of-leave men (conditionally released convicts) as an inducement to work, or conversely, withheld as a means of punishment. 3, 4 Home-grown tobacco was outlawed after initial plantings, since producing food for the new colony was deemed a priority. Illegal crops continued to flourish, however, and in 1803 tobacco growing was sanctioned once more. 4 According to a contemporary observer in 1819, 80 or 90% of male labourers were smokers. 4 In contrast, few European women smoked; those who did being convicts, prostitutes and members of the serving underclass, continuing a practice learned in English prisons; or according to later folklore, stout-hearted characters working in areas of male-dominated employment or living by their wits in the bush. 2 Pipe smoking was the most common means of tobacco consumption in the 19th century, with imported leaf coming from Brazil, and later, North America, to supplement the local produce. 4 The habit of chewing plug tobacco, which was popular in the United States of America, was never more than a minority behaviour in Australia. 4 Partially machine- and handmade cigarettes were first developed in England in the mid-1800s, and totally mechanised production was possible by the 1880s. Although initially dismissed as effeminate by some and as the choice of dandies or larrikins by others, the comparative cheapness and convenience of mass produced cigarettes changed the way Australians smoked forever. The cigarette became ubiquitous in the trenches of the First World War, during which more than 60% of tobacco donated to the Allies on the Western Front as part of their rations arrived in the form of cigarettes. 2 Consumption levels by the Allied Armies also increased dramatically, escalating by up to 70% compared to levels used pre-war. 5 * The history of tobacco use among Australian Aboriginal peoples and Torres Strait Islanders, including traditional use of naturally occurring plants that contain nicotine and the subsequent introduction of smoking by European settlers, is discussed in detail in Chapter 8. Section: 1.1

10 6 Tobacco in Australia: Facts and Issues Meanwhile attitudes towards smoking among women had begun to change as well. While clandestine smoking may have been indulged in by the avant-garde and the fashionable prior to the First World War, the changes in society during the 1920s brought female smoking into the open, and in the following decades advertising began specifically to target women. 6, 7 The increasing engagement of women in the paid workforce, particularly with the outbreak of the Second World War, led to greater social and financial freedom for many women, which in turn fuelled higher smoking rates. 2, 6 By the end of the war, more than a quarter of Australian women were smokers, along with almost three quarters of adult males. 8 Although the second half of the 1900s brought confirmation that tobacco use is a major cause of death and disease, female smoking continued to increase, peaking at one third in the mid-1970s, by which time smoking in males had begun to decline. 9, Overview of major Australian data sets Several series of surveys investigating adult smoking behaviour in Australia have been undertaken in recent decades, providing a wealth of information. The most comprehensive are: << the National Health Surveys, conducted approximately five-yearly by the Australian Bureau of Statistics with the first including routine questions on smoking behaviour undertaken in << the National Drug Strategy Household Surveys, undertaken by the National Drug Strategy (formerly the National Campaign Against Drug Abuse), commencing in 1985 and conducted every two to three years << surveys undertaken by research groups under the auspices of the Cancer Council Victoria (TCCV, formerly the Anti-Cancer Council of Victoria) at three-yearly intervals, from 1974 to , 10, The Centre for Behavioural Research in Cancer (CBRC), a unit within TCCV, has extended this set with data from National Drug Strategy Household Surveys (NDSHS), which since 2001 have assessed smoking status using a methodology considered sufficiently similar to that of TCCV 30 to extend the trendlines. 29 Additional analysis * has produced the most consistently collected and detailed trends data available for Australia, spanning the years from * Data on adult prevalence presented in this chapter originate from new, previously unpublished analyses undertaken by the Centre for Behavioural Research in Cancer, within the Cancer Council Victoria. Prevalence data for have been re-analysed and extended, excluding individuals aged below 18 and weighting the data sets to 2001 census data based on five standard categories of age and sex. Information presented here therefore differs slightly from that published in prior journal articles describing Australian adult prevalence of smoking from Survey data for 2001, 2004 and where it is available, for 2007, are taken from the National Drug Strategy Household Surveys, undertaken by the Australian Institute of Health and Welfare, and analysed by the CBRC. The source files used are listed in the following Notes on Methodology. Notes on methodology: TCCV data were collected as part of an omnibus survey conducted by the same national market research company in each survey year. A random sample of households across Australia was selected for surveying and interviewers conducted face to face surveys with respondents aged 14+ in their home. The original analyses of data from these surveys were based on data from respondents aged 16 and over. The NDSHS is also a survey of a random sample of men and women across Australia, with respondents aged 14+. A market research company has conducted the field work for the study and collected the data using three methods: (a) face to face household interviews; (b) drop and collect questionnaires (interviewer contacts household, identifies respondent, and leaves a questionnaire for them to complete by themselves); and (c) computer assisted telephone interviews. Only data collected by the first two methods are used here as these data collection methods most closely matched those used for TCCV surveys. Data from the NDSHS have also been re-analysed to include responses only from individuals 18 and over, using the following source files: Australian Institute of Health and Welfare. National Drug Strategy Household Survey, 2001 [computer file]. Canberra: Australian Social Science Data Archive, The Australian National University; Section: 1.2

11 Chapter 1: Trends in the prevalence of smoking to Preliminary data from the 2007 NDSHS became available for external use just prior to publication. Preliminary estimates for prevalence of smoking by sex and age groups from this survey are therefore also reported here, but estimates for other variables are not yet available for << the National Tobacco Campaign Evaluation surveys, which measured prevalence between , predominantly reporting on a sample aged which formed the primary target for the campaign. 31 Discussion in this chapter will draw on these and other sources, but most analysis is based on the new data series generated by the CBRC (as described in the footnote on page 6). Changes in the volume of tobacco consumed are discussed in Chapter 2. Table 1.1 Percentage of current smokers* in Australia, Year Male Female Prevalence of smoking adults Measurements of the prevalence of smoking in Australia first became available in Limited survey data 8 are available for the years between then and 1974, when the (then) Anti-Cancer Council of Victoria conducted its first national survey. 9, 10 These early data show that in around the middle of the last century, a clear majority of males aged 16 and over were smokers, compared to about one quarter of females (Table 1.1). In the following decades smoking among men declined, probably in response to the initial publicity regarding the health effects of smoking which first emerged in the 1950s and early 1960s Women have always had a lower prevalence of smoking than men, but smoking among women continued to increase in the 1970s. The findings of the early studies from the Cancer Council Victoria are broadly confirmed by those of a survey by the Australian Bureau of Statistics undertaken in 1977, which found that 36% of the adult population (aged 18 and over) were smokers; 43% of men and 29% of women. 36 Table 1.2 shows the proportion of smokers in the population aged 18 and over from 1980 to The prevalence of smoking declined for both sexes over this period, the most dramatic drop occurring among males between 1983 and 1986, when prevalence decreased by 16%. The differential in smoking rates between the sexes has also continued to close (while remaining statistically significant), largely due to greater * Includes persons smoking any combination of cigarettes, pipes or cigars. Age range for 1945, 1964 and 1969 not specified. Data for 1974 and 1976 are for people aged 16 and over. Sources: Woodward, 8 Gray and Hill9, 10 Table 1.2 Prevalence of current smokers* in Australia aged 18+, **^ Year Male Female % of total adult population previous footnote continued Australian Institute of Health and Welfare, the Australian Government Department of Health and Ageing. National Drug Strategy Household Survey, 2004, [computer file]. Canberra: Australian Social Science Data Archives, The Australian National University; Australian Institute of Health and Welfare. National Drug Strategy Household Survey 2007: First Results. [Computer File]. Canberra: Australian Social Science Data Archive, The Australian National University; The two surveys use different questions to define current smoking. In TCCV surveys, the question for assessing smoking status (which remained unchanged for the duration of the survey period) asked respondents to classify themselves as a current smoker of cigarettes or cigars or pipes, an ex-smoker of any tobacco product, or a never smoker. In the NDSHS surveys, smoking status is ascertained by asking respondents if they have ever tried a cigarette or smoked a full cigarette, and then enquiring of respondents who say yes, whether they have smoked more than 100 cigarettes in their lifetime. Respondents indicating that they have smoked more than 100 cigarettes are asked: How often do you now smoke cigarettes, pipes, or other tobacco products? and are asked to select one of the following responses: daily ; at least weekly ; less often than weekly ; not at all but I have smoked in the past 12 months, or not at all and I have not smoked in the past 12 months. Respondents indicating that they smoke daily or at least weekly are classified as current smokers. A calibration study 30 of the two different approaches has found that they produced the same estimates of smoking prevalence, indicating that these data sets can reasonably be combined to analyse trends. ^ See footnote on page 6 for explanatory notes regarding methodology used in attaining this data set * Includes persons smoking any combination of cigarettes, pipes or cigars. ** All data except 2007 weighted to 2001 census population data Source: Centre for Behavioural Research in Cancer Section: 1.3

12 8 Tobacco in Australia: Facts and Issues Figure 1.1 Prevalence of current smokers* in Australia aged 18+, **^ ^ % See footnote on page 6 for explanatory notes regarding methodology used in attaining this data set * Includes persons smoking any combination of cigarettes, pipes or cigars ** All data except 2007 weighted to 2001 census population data Source: Centre for Behavioural Research in Cancer Section: Figure 1.2 Prevalence of current smokers* in Australia aged 18+, males and females**^ ^ % Male 18 plus Female 18 plus See footnote on page 6 for explanatory notes regarding methodology used in attaining this data set All data except 2007 weighted to 2001 census * Includes persons smoking any combination of cigarettes, pipes or cigars. ** All data except 2007 weighted to 2001 census population data Source: Centre for Behavioural Research in Cancer numbers of men quitting smoking during the mid-to-late 1980s. However, the overall rate of decline seen during the 1980s did not continue into the 1990s, when the prevalence of smoking levelled at about 26%. The trend of gradual decline resumed for both sexes after 1998, but slowed again between 2001 and Data for 2007 show a statistically significant decrease in the prevalence of smoking among adult males, females, and the total population since 2004 (Figures 1.1 and 1.2) Hill and colleagues have suggested that these accelerations and decelerations in decline of smoking prevalence correlate with the level of tobacco control activities occurring at the time. 28, 29 The drop in male smoking rates seen in the early 1980s coincided with a period of new, well-funded media-led Quit campaigns 29 and an upsurge in debate about tobacco control issues in the media, fuelled by the outspoken campaigning of groups such as the Australian Council on Smoking and Health (ACOSH) and Action on Smoking and Health (ASH Australia), and the widely publicised activities of the fringe groups MOP UP and BUGA UP. * Conversely, the steady prevalence rates in both sexes seen during the 1990s corresponds with a lull in legislative activity concerning tobacco advertising and smoking restrictions, and also with a sharp reduction in per capita expenditure on public education campaigns. 28 The subsequent downturn in smoking prevalence seen by the end of the 1990s may be attributable to the combined effects of increased tobacco taxes, 37 additional smokefree legislation, and the National Tobacco Campaign (NTC), a mass-media led program aimed at encouraging cessation that was launched in June and concluded in May (see also Chapter 10) The ongoing close relationship between tobacco control activities and trends in smoking prevalence confirms the importance of continuous review of policies and prevention programs. Despite the decline in smoking rates shown in Table 1.2, smoking remains a leading cause of death and disease in Australia, killing about 14,900 people annually. 39 Since about one-fifth of the adult population currently smokes, and because half of these smokers can be expected to die because of their tobacco use if they do not quit, 40 the sequelae of tobacco-caused death and disease will remain for decades to come. Mortality caused by tobacco use is discussed in Chapter Prevalence of smoking young adults Young adults of both sexes have the highest smoking rates in the community. Table 1.3 compares smoking rates for men and women in three age groups spanning young adulthood to early middle age, between 1980 and The prevalence of smoking has declined over the study period for both sexes in all age groups, and over the passage of time, smoking rates have converged across the age * MOP UP and BUGA UP were acronyms for The Movement Opposed to the Promotion of Unhealthy Products and Billboard Utilising Graffitists Against Unhealthy Promotions respectively. Readers interested in the history and activities of these lobbying groups are referred to in the first instance to: Chapman, S. Civil disobedience and tobacco control: the case of BUGA UP. Billboard Utilising Graffitists Against Unhealthy Promotions. Tob Control 1996; 5: (Available from

13 Chapter 1: Trends in the prevalence of smoking 9 groups as well. As among the general population (Table 1.2 above), the trend in decline levelled off during the 1990s in young adults, before falling again in the late 1990s and early 2000s. When data within each age group are combined for men and women, the falls recorded between 2001 and 2004 are statistically significant only for the youngest group (18 24). The fall in smoking prevalence in this age group continued between 2004 and 2007, possibly reflecting the decline in smoking among teenagers since 1999 see Section 1.6. The fall in smoking prevalence between 2004 and 2007 among year-olds was statistically significant among males, females and all persons. Up until 2004, the proportion of adult smokers aged has been very similar to the proportion aged 25 29, with both declining at a similar rate since In 2007 the proportion of year-olds smoking dropped sharply and is now lower than the proportion of year-olds. Before 1995, significantly more adults in the year-age group smoked than those aged between 30 and 39. Between 1995 and 2004 the differential across these age groups was no longer statistically significant. In addition smoking prevalence among year-old males was significantly lower than among year-old males. Prior to 2007 younger people were consistently more likely to smoke than those over the age of 40. However in 2007 people aged were only more likely than those aged over 60 years to be smokers (Figure 1.3). Smoking patterns among the Australian population aged 40 and over are discussed in the following section. For the most part, young men and women now share similar patterns of smoking. The higher rates of smoking among males in most age groups during the 1980s became less apparent in the 1990s. In 2004 and 2007, the sex difference in smoking behaviour was statistically significant only in the age bracket. Independent analysis of NDSHS data for 2001 and 2004 has indicated that the convergence in smoking prevalence between the sexes is due to fewer younger males becoming regular smokers, whereas females have been more likely to take up smoking Prevalence of smoking middle-aged and older adults As noted in the preceding section, people under 40 are more likely to smoke than those in older age groups. Reflecting smoking patterns from earlier decades, older men are more likely to have smoked at some time in their lives than younger men, and older women are less likely ever to have smoked than younger women. Decreasing smoking rates among the older population reflect increased quitting activity, older age groups of both sexes having the highest quit proportions (defined as the proportion of ever smokers who have stopped smoking). 28 Tobacco-caused death and illness occurring among smokers in older age groups are also significant factors in declining smoking rates seen in the older population, with the greatest proportion of burden of disease due to smoking affecting those aged between Table 1.3 Young adults percentage of current smokers* by age group, sex and total population for age group, **^ Age group Sex Male Female Total Male Female Total Male Female Total ^ See footnote on page 6 for explanatory notes regarding methodology used in attaining this data set * Includes persons smoking any combination of cigarettes, pipes or cigars ** All data except 2007 weighted to 2001 census population data Source: Centre for Behavioural Research in Cancer. Section: 1.5

14 10 Tobacco in Australia: Facts and Issues Table 1.4 Middle-aged and older adults percentage of current smokers* by age group, sex and total population for age group, **^ ^ Age group Sex M F T M F T See footnote on page 6 for explanatory notes regarding methodology used in attaining this data set * Includes persons smoking any combination of cigarettes, pipes or cigars ** All data except 2007 weighted to 2001 census population data Source: Centre for Behavioural Research in Cancer Figure 1.3 Prevalence of current smokers* in Australia aged 18+, by age group**^s ^ % See footnote 2 for explanatory notes regarding methodology used in attaining this data set * Includes persons smoking any combination of cigarettes, pipes or cigars ** All data except 2007 weighted to 2001 census population data Source: Centre for Behavioural Research in Cancer Table 1.4 and Figure 1.3 show that smoking rates have declined in smokers aged 40 and over since the early 1980s. Rates stabilised during the early to mid-1990s, before returning to a pattern of decline. The decline in smoking prevalence between 1998 and 2004 was statistically significant among year-olds but not in those aged over 60. Although smoking rates did not change between 2001 and 2004 for either age group, there was a significant decline in smoking prevalence among women and all people aged years between 2004 and The 2004 National Drug Strategy Household Survey provides more detailed information on smoking prevalence in older Australians. In 2004, 11% of people aged between 60 69, 7% of people aged between 70 79, and 3% of people aged 80 or more smoked on a daily basis Prevalence of smoking secondary students More than 80% of smokers become addicted to nicotine as teenagers. 44, 45 According to the NDSHS (2004), the average age of initiation of tobacco use among those who had ever smoked was An estimated 22,077 Australian school children progressed from experimental to established smoking behaviour in * National surveys of smoking patterns in Australian secondary students have been coordinated by the Centre for Behavioural Research in Cancer (within the Cancer Council Victoria) at three-yearly intervals since These data are reported in this chapter since they provide the most detailed consistently collected statistics available. ** The prevalence of smoking among children increases with age. Table 1.5 shows that in 2005, 54 smoking was very much a minority behaviour among 12-year-olds, but that by the age of 17, 19% of males and 17% of females had smoked in the previous week. Over the survey period the difference in the proportion of male and female students smoking in the past week has reduced considerably. In 2005, a similar proportion of males and females were smoking in each age group except for 16-year-olds, among whom significantly more females than males had smoked. Reflecting patterns reported for adults (Section 1.3 above), smoking among secondary students declined during the 1980s but stalled during the first half of the 1990s. Between 1996 and 2005 a significant fall in smoking prevalence was seen in all age groups and the prevalence rates recorded for 2005 are the lowest since the survey series began in 1984 see Figure 1.4. The return to a downward trend in smoking among teenagers coincides with the launch in 1997 of the high profile, media-led and nationally coordinated National Tobacco Campaign. 55 Although not specifically * Using the methodology outlined in White and Scollo 46 ** A second national series reporting smoking patterns among teenagers commenced with the National Campaign Against Drug Abuse Household Survey in Now known as the National Drug Strategy Household Surveys, these reports provide information on the population aged 14 and over, but most do not present information for individual year of age The 2004 survey reports on adolescents in two age brackets (12 15 and 16 17). 20 Section: 1.6

15 Chapter 1: Trends in the prevalence of smoking 11 targeted at children, there is evidence that teenagers were well aware of the campaign, 56 and that the program s success in reducing adult smoking rates appears also to have had the unintended but welcome effect of reducing smoking in younger age groups as well. 52 Other tobacco control activities over the same period, for example increased tobacco taxes, publicity surrounding the introduction of smokefree environments, and stricter enforcement of regulations relating to sales to minors and smoking in public and other places, are also likely to have contributed to downward pressure on smoking rates among secondary school students. A limitation of the data series reported in this section is that school students are required to remain in formal schooling only up until the age of 15, meaning that smoking prevalence measured among 16- and 17-year-olds attending school is not fully representative of all teenagers, particularly earlier in the survey period. However, with school retention rates increasing since the beginning of the study period, and teenagers now being strongly encouraged to remain in school until the completion of Year 12 or its vocational equivalent, 57 the most recent figures seem likely to reflect more accurately smoking prevalence rates among older teenagers than in the earlier years. Even so, it is probable that smoking rates reported for the two older age groups in Table 1.5 at least to some degree underestimate overall prevalence in 16- and 17-year-olds. Teenagers who are committed to school, and have high academic aspirations, are less likely to smoke. 58 Conversely, the transition to the workplace may subject some school-leavers to higher levels of peer smoking behaviour if they pursue a semi-skilled or unskilled vocation. Workers in blue collar occupations are more likely to be smokers (Section 1.7.2). In the National Drug Strategy Household Survey conducted in 1998, 18 they were also more likely to report that they worked in an environment without restrictions on smoking (see Chapter 9 for a summary of unpublished data from this survey). 1.7 Trends in the prevalence of smoking by socioeconomic status In Australia 29, 59, 60 and many other countries, 61, 62 smoking behaviour is inversely related to socioeconomic status, with disadvantaged groups in the population being more likely to take up and continue smoking. The authors of a seminal British report on poverty and smoking have observed that one can almost study social disadvantage itself through variations in smoking prevalence. 63 p78 A number of sociodemographic variables are closely connected with the likelihood of smoking. Siahpush and Borland 64 have examined the correlation of smoking behaviour with several factors, including education, family income, and Index of % & 17 years 12 to 15 years Figure 1.4 Prevalence of Australian secondary school students who report smoking in last week, Australia year-olds and 16- and-17-year-olds Source: White and Hayman Table 1.5 Percentage of Australian secondary students who smoked in the last week, Age Sex M F M F M F M F M F M F Sources: Hill et al, White and Hayman53, 54 Section: 1.7

16 12 Tobacco in Australia: Facts and Issues Relative Socio-economic Disadvantage (IRSD). * This research found that all three measures of socioeconomic status education, income and IRSD were independently and significantly related to the likelihood of smoking for both sexes. Of these three measures, IRSD was most strongly related to smoking status. Individuals falling within the highest IRSD category of disadvantage were about twice as likely to smoke as individuals in the lowest IRSD category, irrespective of individual levels of education and income. This finding suggests that the influence of neighbourhood is an important contributing factor to whether an individual smokes or not. Siahpush and Borland describe this as a contextual effect, occurring because smoking is normative behaviour in a particular environment, or because there are other physical, cultural, social or economic factors in those areas that encourage or lead to smoking. 64 The relationship between smoking and social disadvantage is discussed in greater detail in Chapter 9. Differences in smoking rates among socioeconomic groups result in different patterns of tobacco-caused ill health and disease. For discussion, see Chapter 3, Section 31. Table 1.6 Prevalence of current smoking* among Australian adults by educational level and sex, **^ Smoking and educational level Increasing education levels are associated with decreased likelihood of smoking. Table 1.6 shows that between 1986 and 2004, people with the highest levels of education had consistently lower levels of smoking than other members of the community. Highest level attained* Year Year 9 or less Males Females Persons Years 10 and 11 Males Females Persons Year 12 or post secondary qualifications Males Females Persons Highest level attained* Year Trade qualification Males Females Persons University graduate or attended some university Males Females Persons Note: Questions assessing education levels achieved differed between TCCV and NDSHS surveys, so categorisation into the different education groups has been adjusted accordingly. Individuals who in TCCV surveys had undertaken post secondary school study have been reclassified as having attained year 12. Individuals who completed a trade certificate or finished studying at a technical or commercial college are classified as having a trade qualification. Individuals who attained a non-trade certificate are classified according to their highest level of schooling. Individuals who started a university course, are still at university or have completed a university degree are classified as university graduate or attended some university. ^ See footnote on page 6 for additional explanatory notes regarding methodology used in attaining this data set * Includes persons smoking any combination of cigarettes, pipes or cigars. ** Weighted to 2001 age and gender census data. Source: Centre for Behavioural Research in Cancer. * IRSD is an area-specific socioeconomic measure applied by the Australian Bureau of Statistics, which takes into account a number of variables including income, education, occupation, housing, household composition and English fluency of residents. See Siahpush and Borland 64 for further discussion. Section: 1.7.1

17 Chapter 1: Trends in the prevalence of smoking 13 Analyses of combined data for males and females, adjusting for age and sex, show that the prevalence of smoking found in every education level in 2004 was significantly lower than that found in The decline in prevalence of smoking was most substantial among those who had graduated from university or had some university education, those who finished secondary school and for those who stayed at school up until Year 9. For people with a trade qualification and those staying in school until Years 10 or 11, most of the decline in prevalence occurred in the 1980s. For these education groups, the prevalence of smoking in 2004 was generally not significantly different from that found throughout the 1990s. Looking at the data by year, from 1983 onwards those who completed Year 12 had significantly lower levels of smoking than those who left school after Year 9. In analyses that do not control for age and sex, the difference in smoking prevalence between those with education up to Years 9, and those with education up to Years 10 and 11 was only statistically significant in 1986, 1998, 2001 and Population trends for higher rates of school retention 65 and increased attainment of post-school qualifications 66 are likely to be contributing to the overall decline in smoking in the Australian population. Table 1.7 Prevalence of current smoking* by occupational group and sex, **^ Classification *** Upper white collar Males Females Persons Lower white collar Males Females Persons Upper blue collar **** Males Females Persons *** Lower blue collar Males Females Persons Not in paid work Males Females Persons Smoking and occupation Smoking behaviour is clearly stratified by occupational level, increasing occupational prestige correlating with a decreased likelihood of smoking. In 2004, smoking prevalence among lower blue collar workers was about two and a half times higher than in upper white collar workers, although prevalence among all socioeconomic groups is in decline. Overall, in 2004, 14% of individuals in upper white collar employment were smokers, compared with 35% of those working in lower blue collar employment. Table 1.7 and Figure 1.5 show trends in smoking prevalence by occupation level. Occupation level is based on the current occupation of survey respondents. Respondents who were not employed at the time of the survey (such as retirees, or people engaged in domestic duties) were not asked for a previous occupation and are classified as not being in paid work. Adjusting for age and sex, individuals in upper white collar occupations have reported significantly lower rates of smoking than all other groups for every study year except for 1980, when there was no difference in smoking levels between those not in the labour force and those in lower white collar occupations, and then in 1995 when there was no difference in smoking levels for those with upper and lower white collar occupations (see Table 1.7). For most survey years the prevalence of smoking among lower blue collar workers has been significantly higher than for all other occupational groups, except for in 1980 ^ See footnote on page 6 for explanatory notes regarding methodology used in attaining this data set * Includes persons smoking any combination of cigarettes, pipes or cigars ** Weighted to 2001 age and gender census data *** Upper white collar: includes professionals, business owners, executives, farm owners, semi-professionals Lower white collar: including sales; other white collar Upper blue collar: includes skilled workers Lower blue collar: semi-skilled, unskilled, farm workers Not in paid work: including those engaged in domestic duties, students, retired people, and respondents looking for work **** Note: In earlier survey years, women were more likely to be placed in the category not in paid work. In addition, in surveys before 2001 few women were included in the upper blue collar (UBC) category and therefore smoking prevalence estimates for this group should be treated with caution. As a result of the low numbers of women in the UBC category, smoking prevalence figures for total UBC workers are closer to those for UBC males Source: Centre for Behavioural Research in Cancer. Section: 1.7.2

18 14 Tobacco in Australia: Facts and Issues and 1992, when there was no statistical significance in the difference between smoking behaviour among lower blue and upper blue collar workers. In the 1980s, smoking among the group categorised as not in paid work was generally lower than for all employment groups other than upper white collar workers. From 1992 onwards, the prevalence of smoking in the not in paid work group has been closer to those in lower white collar occupations. While the not in paid work category is likely to include a proportion of socioeconomically disadvantaged people, who as a demographic group demonstrate a higher prevalence of smoking, as indicated above this category also includes retired people (older people being less likely to smoke than younger people see Table 1.4), those engaged in domestic duties (more likely to be female than male, and hence to have a lower smoking prevalence Table 1.2), and students in post-secondary education (who are less likely to be smokers than those with a lower level of education level Table 1.6). Comparing smoking behaviour within individual occupational groups over time and adjusting for age and sex, the prevalence of smoking declined during the 1980s for each occupational group, before levelling off in the 1990s. The decline in prevalence of smoking was significant between 1980 and 2004 for all occupational groups. However for lower white collar and upper blue collar workers there has been little change in smoking prevalence between 1995 and Among lower blue collar workers, smoking prevalence in 2004 was significantly lower than estimates found in all other years except 1992 and % Lower blue Upper blue Lower white Upper white The decline in smoking between 1980 and 2004 has been proportionately greater among white collar workers than blue collar workers. Overall, prevalence of smoking among upper white collar workers halved over this study period, while among lower blue collar workers, prevalence dropped by about 30%, suggesting that the differential in prevalence between the highest and the lowest occupational groups is widening over time, a pattern which has been observed in the United Kingdom as well. 67 However the lower prevalence of smoking among those with higher occupational status is a result of fewer individuals in these groups having taken up smoking in the first place, rather than being more successful at quitting smoking. 28 Figure 1.5 Prevalence of current smokers* in Australia aged 18+, by occupational status**^ ^ See footnote on page 6 for explanatory notes regarding methodology used in attaining this data set * Includes persons smoking any combination of cigarettes, pipes or cigars ** Weighted to 2001 census Source: Centre for Behavioural Research in Cancer. 1.8 Trends in prevalence of smoking by country of birth According to Census data, about three out of every 10 Australian residents were born overseas, and about two in 10 Australians speak a language other than English at home. 68 There is considerable variation in prevalence of smoking among individuals born in different countries who have migrated to Australia. Table shows that the highest rates of smoking occur among migrants from Other Oceania (comprising New Zealand, Melanesia, Micronesia and Polynesia, but excluding Hawaii 69 ), and North Africa and the Middle East. It should be noted that in some of the regions listed below, smoking is predominantly a male behaviour, but since the data in Table 1.8 do not include a break down by gender, any sex differential in smoking is not apparent. Section: 1.8

19 Chapter 1: Trends in the prevalence of smoking 15 People migrating to Australia after 1996 are slightly less likely to be smokers than those arriving prior to 1996, and are also less likely to smoke than the Australian population as a whole (Table 1.2). In households where the main language spoken at home is English, the prevalence of smoking is higher than in those in which another language is spoken. These findings have been confirmed by the National Drug Strategy Household Survey for As well as concealing sex differences, the regional summaries provided in Table 1.8 are likely to disguise higher smoking rates within some smaller population sub groups. For example studies have shown that in the Arabspeaking population in Sydney, more than 50% of both males and females smoke, 70 that among the Sydney-based Lebanese community, about 49% of males and 29% of females are smokers, 71 and that male members of the Vietnamese community in Sydney have smoking rates of 53%. 72 Although adult prevalence of smoking is higher in some groups with a non- English speaking background (NESB), studies from New South Wales have consistently shown that children within these families have a lower prevalence of smoking than their counterparts from English-speaking homes See Chapter 5 for further discussion. For more information on smoking among people of culturally and linguistically diverse (CaLD) backgrounds see Chapter 9. Cessation programs designed to suit the needs of CaLD groups are discussed in Chapter Prevalence of tobacco use among Aboriginal peoples and Torres Strait Islanders Note: A brief summary of current prevalence data for Aboriginal peoples and Torres Strait Islanders is presented in this section. For extended discussion refer to Chapter 8 Tobacco use among Aboriginal peoples and Torres Strait Islanders. Aboriginal and Torres Strait Islander people make up 2.3% of the Australian population. 68 Tobacco use is widespread among the Aboriginal and Torres Strait Islander populations. 76, 77 Table 1.9 shows smoking rates among Indigenous people, by sex and age group, for Half of the combined Aboriginal and Torres Strait Islander population are current daily smokers, which is more than double the prevalence among the Australian population as a whole. Smoking rates have remained stable, virtually identical figures being reported in previous national surveys from 1994 (52%) 78 and 2002 (51%). 76* Table 1.8 Smoking among persons aged 18 years and over, by country of birth, period of arrival in Australia, and main language spoken in the home, Percentage Country of birth of current daily smokers (rounded) Australia 22 Other Oceania 26 United Kingdom 19 Other North-West Europe 18 Southern and Eastern Europe 18 North Africa and the Middle East 23 South-East Asia 16 All other countries 15 Born overseas Arrived before Arrived Main language spoken at home English 22 Language other than English 17 Source: National Health Survey * The National Drug Strategy Household Survey for 2004, as in previous years, reports on a small Indigenous sample. The prevalence of smoking reported in the 1994, 1998 and 2001 surveys was similar to that of the other national surveys discussed above. However the survey for 2004 returned a much lower population prevalence figure of 39%, down from 49% in Given the consistently higher prevalence data published by other larger national surveys, it is likely that the NDSHS figure is an outlier. This is probably due to differences in sampling between the 2001 and 2004 surveys. It is known that there is considerable variation in smoking rates between various Indigenous communities, which if not sampled in a comparable manner between surveys, could be expected to skew results. Refer to Chapter 8 for related discussion. Section: 1.9

20 16 Tobacco in Australia: Facts and Issues Table 1.9 Percentage of current daily smoking* among Aboriginal peoples and Torres Strait Islanders by sex and age group, Age group Total Males Females People The substantially higher prevalence of smoking in Australia s Indigenous population may be attributable to a complex range of interrelated factors. Aboriginal peoples and Torres Strait Islanders are by far the most socioeconomically disadvantaged subgroup in the Australian population, 79 which in itself is a predictor of increased smoking behaviour (see Section 1.7). Additionally, smoking patterns are also likely to reflect cultural aspects particular to this subpopulation, including the traditional customs of sharing and kinship bonding For each age group among both men and women, this population group shows a higher smoking prevalence compared to the overall Australian population. Highest rates of smoking are among males and females aged between Overall, males have a slightly higher prevalence of smoking than females (51% compared to 49%). 77 * Current daily smokers are those who smoke one or more cigarettes (either manufactured or RYO), cigars or pipes per day, on average. Chewing tobacco and smoking of substances other than tobacco are excluded. Source: National Aboriginal and Torres Strait Islander Health Survey Prevalence of smoking in other high risk sub-groups of the population Discussion of general trends in smoking prevalence in Australia overlooks population sub-groups which may have much higher smoking rates, or for whom smoking causes special problems. Individuals with lower socioeconomic status or lower educational attainment are more likely to smoke, as discussed in Section 1.7. Aboriginal peoples and Torres Straits Islanders, discussed in the preceding section and in detail in Chapter 8, also show substantially higher smoking rates than the rest of the population, as do members of some other culturally and linguistically diverse communities (Section 1.8). Following is brief discussion about other population groups among whom smoking prevalence is either higher than overall Australian prevalence, or for whom smoking poses greater than usual health risks Smoking in pregnancy Smoking patterns in pregnancy are of particular importance since tobacco use harms the unborn child as well as the pregnant woman. 83 The Australian Institute for Health and Welfare s National Perinatal Data Unit (NPDU) reports data on births in Australia. It collects information concerning both the mother (including demographic profile and matters relating to the pregnancy and birth) and the baby (such as sex, birthweight and other health indicators). 84* The NPDU reports that in 2005, 17.4% of women smoked during pregnancy 84 (Table 1.10), down marginally from 19.2% in There was considerable variation between states, probably in part due to different means of ascertaining smoking status (see notes to Table 1.10). Lowest smoking rates of about 14% were recorded in New South Wales and the ACT, and the highest recorded prevalence of smoking in pregnancy was reported for the Northern Territory (31%). The NDSHS (2004) found that 20% of women who were pregnant or breastfeeding continued to smoke, 43 down from 23% in * An earlier report issued by the NPDU reports specifically on smoking, but uses a more limited data set and presents data from Readers seeking a more detailed analysis of Australian data on smoking in pregnancy are referred to this report, as well as Laws et al. 84 Section:

21 Chapter 1: Trends in the prevalence of smoking 17 As well as regional variations noted in Table 1.10, there are also variations in the prevalence of smoking during pregnancy in certain sub-populations, presumably reflecting smoking behaviour in these groups within the wider population. For example women who were most disadvantaged were more than four times more likely to smoke than women who were least disadvantaged (28% compared to 6%). Women with Aboriginal or Torres Strait Islander backgrounds were more than three times more likely to smoke during pregnancy than non-indigenous women (53% compared with 16%). Likelihood of smoking during pregnancy decreased with maternal age. Forty-two percent of teenagers smoked during pregnancy. 85 Other research has shown that women without a partner, the less educated, 87 those with lower socioeconomic status 87, 88 and women with a psychiatric disorder 89 are more likely to smoke during pregnancy. The Australian National Tobacco Strategy has identified expectant and new parents as a priority target group for future education and cessation support interventions. 90 The health consequences of smoking and exposure to second-hand smoke during pregnancy are discussed in Chapters 3 and 4 respectively. For information on issues related to quitting smoking during pregnancy, refer to Chapter Smoking and mental illness Mental health problems are common within the Australian population, with one in ten Australians (children and adults) reporting a long-term mental or behavioural issue. 14 Mental health problems include both mild and occasional problems as well as more debilitating conditions such as major depression and very serious psychotic illnesses such as bipolar disorder and schizophrenia, characterised by fundamental distortions of thinking, perception and emotional response. 91 Individuals with mental health conditions have a higher prevalence of smoking and those who smoke tend to smoke more heavily than the general population Higher rates are observed in those with severe mental illness than in those with milder mental health problems and highest rates are observed among those with a diagnosis of psychosis. 93 Australian research has reported smoking rates of up to 35% among patients suffering from common mental disorders 14, 94 (defined as affective, anxiety or substance use). An international meta-analysis of studies on smoking among people with schizophrenia reported pooled prevalence of 60%. An Australian study found rates of 73% in men and 56% in women suffering from psychotic illnesses such as schizophrenia. 91 Among mentally ill in-patients with co-existing alcohol and other drug problems, smoking rates as high as 90% have been observed. 95 People with mental health illnesses who live in institutions have higher rates of smoking than those living in the community. 93 These excessive smoking rates contribute to higher levels of tobacco-caused morbidity and mortality among the mentally ill. 96 Smokers living with mental illness are severely disadvantaged both by their illness and by expenditure of limited resources on tobacco products see Chapter 9 for further discussion. Smokers who suffer from severe mental health illnesses, and those living in institutions, have been identified in the Australian National Tobacco Strategy 90 as requiring specialised strategies to assist in cessation. For further discussion on cessation in this target group, see Chapter 7. Table 1.10 Women who smoked during pregnancy by Australian state* and territory, 2005 State or Territory % of smokers (self-reported) New South Wales 14.3 Queensland^ 20.4 Western Australia 17.1 South Australia** 23.2 Tasmania 27.6 Australian Capital Territory 14.5 Northern Territory*** 31.1 Total 17.4 * Excluding Victoria, for which data were not available. ^ Smoking status in Queensland was reported from 1 July 2005, so information in the table is for July December ** Smoking status in South Australia includes women who quit before the first antenatal visit. *** Smoking status in Northern Territory was recorded at the first antenatal visit. Source: Laws et al. 84 Section:

22 18 Tobacco in Australia: Facts and Issues Lone parents In Australia between 2004 and 2006, 22% of all family groups were led by a lone parent, and on average, one in five children aged less than 15 was being cared for in a family with one parent. 97 Eighty-seven percent of lone parents bringing up children aged under 15 are women. 97 Australian research has found that the overall prevalence of smoking among lone mothers is about 46%, with those younger in age (18 29 years) reporting the highest prevalence (59%). 98 Lone parenthood is associated with social and economic disadvantage, 97 and is discussed further in Chapter The homeless Homelessness is defined as lacking adequate access to safe and secure housing. The 2001 Australian National Census showed that there are about 100,000 homeless people in Australia. 99 Individuals experiencing homelessness have a poorer health status than the general population, with the street homeless (those usually dwelling on streets or in parks, in derelict buildings or other temporary shelters) being the worst affected. 100 Melbournebased research has shown a greatly elevated prevalence of smoking among the homeless (77%), with street homeless reporting higher rates of 93%. 100 For further discussion refer to Chapter The prison population The prevalence of smoking in the prison population is far higher than among the general population, 101, 102 and tobacco use is commonly accepted as part of prison life. 102 It is not unusual for tobacco to be used as currency in gambling or other trade. 102 Research undertaken in 2001 examining smoking in New South Wales prisons found that 78% of male and 83% of female inmates were smokers. 102 Most (95%) inmates smoked RYO cigarettes, a far higher proportion than that seen in the rest of the population; and possibly an indicator of a greater degree of addictedness as well. 102 Forty-one percent of prisoners who smoked reported that they smoked more heavily in prison than when in the community. Illicit drug use was closely connected to tobacco use, with about 90% of individuals who had ever injected drugs, or used cannabis, being smokers as well. 102 Eighty-six percent of inmates aged under 25 were smokers, compared to 64% of prisoners aged over 40. Prisoners who smoked were less likely to have completed their schooling. A small number of smokers had started smoking in prison (7%). 102 The elevated smoking rates in the prison population reflect, to a large extent, increased likelihood of disadvantaged socioeconomic backgrounds in inmates. Indigenous people, drug users, and the less educated are over-represented in the prison system, as are those suffering mental illness. 102, 103 As noted elsewhere in this chapter, each of these factors predicts higher smoking rates. Section:

23 Chapter 1: Trends in the prevalence of smoking 19 The Australian National Tobacco Strategy 90 has identified the prison population as a priority area for future interventions. For further information, see Chapters 7 and Other drug use Tobacco use commonly co-exists with other drug use. The National Drug Strategy Household Survey of 2004 examined tobacco use and use of other substances, whether the drug use occurred simultaneously or on separate occasions (Table 1.11). Smokers were more likely to have used any other drug in the past year, compared with nonsmokers, and male smokers had a higher prevalence of usage compared with female smokers. Overall, smokers were more than four times as likely to have used marijuana than non-smokers, and were more than three times as likely to have used illicit drugs. 43 In 2005, between four and five out of 10 secondary school students who reported having used marijuana, amphetamine, hallucinogens or ecstasy said that they had used tobacco concurrently. 104 Most individuals presenting with substance use disorders smoke tobacco as well. 103 International 92 and Australian 95, 105 research shows that in this population, smoking rates range from 68% 92 to 90%. 95 The relationship between tobacco and other drug use is complex, and may be subject to genetic and neurobiological determinants, as well as psychological and social influences. 106, 107 Cessation interventions tailored to the needs of polydrug users are discussed in Chapter 7, Section Prevalence of use of different types of tobacco product Manufactured cigarettes, roll-your-own (RYO) cigarettes, pipes and cigars Most tobacco consumed in Australia is in the form of factory-made cigarettes. Data on prevalence of use of different types of tobacco product was collected by the Cancer Council Victoria (formerly the Anti-Cancer Council of Victoria) in regular surveys undertaken between 1974 and 1998, and has been reported in the most recent National Drug Strategy Household Surveys. Between 1974 and 1998 a small percentage of male smokers reported using pipes or cigars exclusively (Table 1.12). The National Drug Strategy Household Surveys have also collected data on type of tobacco smoked (Table 1.13). These findings show that manufactured cigarettes remain by far the most popular choice among smokers, and especially among women. Table 1.11 Recent use of other drugs by smokers and non-smokers: proportion of the population aged 14+ by sex, Australia, 2004 Males Females People Other substances Nonsmokersmokersmokers Non- Non- Smokers+ Smokers+ Smokers+ recently* used Percent (rounded) Alcohol Marijuana Any illicit drug Any illicit drug excluding marijuana * Recent is defined has having been used in the past 12 months + Smokers are those who have used tobacco in the past 12 months Source: NDSHS Section:

24 20 Tobacco in Australia: Facts and Issues Table 1.12 Proportion of male and female smokers age 18 years and over smoking different tobacco products, (data not weighted) The NDSHS survey for 2004 found substantial overlap in choice of smoking products among smokers. Although 8% of smokers reported use of cigars and/or pipes, only 1% of smokers used these products exclusively. RYO tobacco was used exclusively by 5% of smokers, and manufactured cigarettes by 70% of smokers. There is some evidence that cigar usage in Australia has increased in the last decade, 108 probably due to the Year Sex Cigarettes (%) Pipes and/ or cigars* (%) 1974 Male 91 9 Female Male 94 6 Female Male 99 1 Female Year Sex Cigarettes (%) Pipes and/ or cigars* (%) 1983 Male 94 6 Female Male 95 5 Female Male 94 6 Female Year Sex Cigarettes (%) Pipes and/ or cigars* (%) 1992 Male 97 3 Female Male 96 4 Female Male 97 3 Female * Pipe/cigar smokers are only those that smoke tobacco in these forms exclusively. Smokers who use a mix of cigarettes and pipes/cigars are included with cigarette smokers. Source: Centre for Behavioural Research in Cancer, unpublished data. Table 1.13 Type of tobacco smoked*, smokers aged 18 years and over, Australia, 2001 and 2004 (data not weighted) Manufactured Cigars or Year Sex cigarettes pipes RYO % 2001 Males Females Persons Males Females Persons * Respondents could select more than one response. Respondents were classified as using the different tobacco product if they indicated at least some use of the product, irrespective of recency of use. Sources: NDSHS and greater profile which these products have received over the past decade both here and internationally, but currently this cannot be discerned from national prevalence data. A large international study on the prevalence and user characteristics of RYO tobacco in Australia and other countries has shown that exclusive RYO smokers are more likely to be male, older in age, to have a lower level of income, and lesser education. 109 Prevalence of use of RYO in Australia reported in this study is similar to that reported by the NDSHS (2004). 20 About one quarter of Australian smokers surveyed made some use of RYO products, 15% combined use of manufactured cigarettes and RYO tobacco, and 9% reported exclusive use of RYO Unbranded loose tobacco ( chop-chop ) Chop-chop is finely cut, unbranded black market tobacco which has been grown, distributed and sold without government intervention or taxation. 110 Due to its comparative cheapness, some smokers have adopted it as an alternative to, or in addition to smoking manufactured tobacco. 80, 111 Questions about the prevalence of usage of chop-chop have been asked in the most recent National Drug Strategy Household Surveys. Between 2001 and 2004, awareness of chop-chop doubled in the total population aged 14 and over from 19% 19 to 38%. 20 In 2004, 23% of those who were aware of chop-chop had smoked it at least once, and of those who had ever smoked it, one in five smoked it half the time or more. Taking into account the total population aged 14 and over, 9% of Australians had smoked chop-chop at least once, and about half of one percent (0.4%) of the total population used chop-chop half the time or more. Males were more likely to have come across chop-chop and to have tried it, than females. 20 Two small surveys undertaken in New South Wales have shown varying degrees of penetrance of chop-chop in the community. 111, 112 Chop-chop is discussed further in Chapter 3, Section and Chapter 10, Section Section:

25 Chapter 1: Trends in the prevalence of smoking Smokeless tobacco products Although widely used overseas, 113 smokeless tobacco products (those intended for sucking or chewing) are little used in Australia and data concerning the prevalence of their use is sparse. An unpublished analysis of the National Drug Strategy Household Survey from 2004 suggests that approximately half of one percent (0.57%) of the Australian population aged 12 or over had used smokeless tobacco in the 12 months prior to the survey. 114 Leaves from naturally occurring nicotine-containing plants were chewed by Aboriginal peoples and Torres Strait Islanders prior to the introduction of conventional tobacco products in the 18th century, first by Indonesian fishermen, and later by European settlers. In some Indigenous communities bush tobaccos and manufactured loose or plug tobaccos are still chewed, either alone or in combination, but overall prevalence of use of these substances is extremely low. 1, 80, Tobacco chewing among the Australian Indigenous population is discussed further in Chapter 8, Section 8.5. The import, sales and marketing of smokeless tobacco products in Australia is controlled by federal legislation. 118 However a recent survey showing that smokeless tobacco products are readily available from some South Asian shops in Sydney suggests that there is sufficient local demand for these products for importers and shopkeepers to risk breaking the law. 119 See Chapter 3, Section 3.33 for further discussion Future smoking rates? With the prevalence of smoking declining among Australian schoolchildren and continued cessation occurring among the population of smokers, it is reasonable to assume that levels of smoking will continue to fall in future decades. 120 Moreover, as smoking is increasingly seen as a minority behaviour, obstacles to its further regulation are likely to become less important as time goes by. 120 This has prompted some speculation that smoking could disappear in Australia by about 2030, 120, 121 much as snuff use did in the 1700s. 121 Perhaps a more pragmatic approach is to examine smoking behaviours in population groups in Australia with significantly lower than average patterns of smoking. 120 One such group is medically trained personnel. Surveys on smoking rates among medical students in Sydney 122, 123 and Australian general practitioners and GP trainees 124, 125 have shown a prevalence of 3 4%. On the assumption that doctors are more informed about, and more often encounter the health consequences of tobacco use than most other occupational groups in the community, this may indicate the lowest baseline smoking rate that can be reasonably expected in a fully informed population. 120 Dentists are also confronted with the oral effects of tobacco use, ranging from bad breath through to cancers of the mouth. Prevalence of smoking among Australian dentists matches that of GPs. 126 The challenge remains to reduce smoking prevalence and its corollary of death and disease in those subpopulations in Australia among whom smoking continues to be widespread. For further information, see Chapter 9. Section: 1.12

26 22 Tobacco in Australia: Facts and Issues 1.13 International comparisons of prevalence of smoking An estimated 1.25 billion adults worldwide are smokers, 127 and international findings that 17% of young teenage school students are also current tobacco users (in one form or another) confirm that tobacco-caused illness and death will continue for many decades to come International comparisons of adult smoking prevalence In general, the prevalence of smoking is declining in industrialised countries in Northern and Western Europe, North America and the Western Pacific region, and is on the increase in some countries in Asia, South America and Africa. 129 As global patterns in tobacco use change, the burden of death can be expected to transfer from the developed world to less wealthy countries. About 80% of the world s smokers now live in low and middle income countries, at least in part due to a lack of adequate tobacco controls. 130 The marketing practices of the tobacco industry in developing countries are particularly aggressive, 127, 129, 131 and the international tobacco industry s efforts to subvert tobacco control activities in developing countries are well-documented. 132 Although the tobacco industry has publicly acknowledged the health consequences of smoking * and is required to conform to stringent regulation in more privileged nations, 129 there is ample evidence that it deliberately exploits the comparative lack of controls in less developed countries. 132, 133 As more countries ratify the Framework Convention on Tobacco Control, an initiative by the World Health Organization to counter the globalisation of the tobacco epidemic 134 (see Chapter 18) it is to be hoped that these activities will be effectively curbed. A paradigm illustrating the typical progression of tobacco use worldwide, first proposed by Lopez et al 61 and later adopted by the World Health Organization, 129 is reproduced here (Figure 1.6). Many (but not all) countries experiences of patterns of tobacco use fit this model. Stage one of the model is marked by a low smoking prevalence (below 20%), generally limited to males and accompanied by little evident increase in tobacco-caused chronic illness. Countries at stage one have not yet become major consumers in the global tobacco economy, but represent untapped potential for the tobacco industry. Some countries in sub-saharan Africa fit into this stage in the model. 129 The importance of tobacco farming in some countries in the region (for example Zimbabwe and Malawi) may act as a deterrent to the introduction of tobacco control policies. Zimbabwe is among the largest producers of tobacco in the world and is a major exporter; and concerns about the health consequences of tobacco use are not high on the national agenda. 135 * As demonstrated, for example, by statements included on the corporate website for British American Tobacco Australia and available from: and on the corporate website for Philip Morris International. ( Section:

27 Chapter 1: Trends in the prevalence of smoking 23 In stage two of the paradigm, male prevalence of smoking has soared to more than 50% in men, and women s smoking rates are now increasing. Uptake of smoking is occurring at an earlier age, and although there is now evidence of increased lung cancer and other chronic illness due to smoking among men, public and political understanding of and support for tobacco control initiatives is still not widespread. Countries that fit into this transitional stage include Japan, some nations within the South-East Asian, Latin American and North African regions, and to a lesser extent, China. (The case of China is discussed further below). 129 Stage three of the epidemic has been reached when smoking prevalence peaks and begins to decline in both sexes; although deaths caused by smoking continue to increase because of earlier high smoking rates. Health education programs are better developed, smoking becomes less accepted among the more educated groups of society, and the climate is increasingly conducive to the introduction of tobacco control policies. Certain countries within Eastern and Southern Europe and Latin America are at this point on the continuum. 129 Evolution into stage four is marked by a continued distinct but gradual downturn in smoking prevalence among both males and females. Male deaths from smoking begin to decline, but female death rates continue to rise, reflecting earlier smoking patterns. Parts of Western Europe, the United Kingdom, the USA, Canada, New Zealand and Australia are at various points on the continuum in the fourth stage of the tobacco epidemic. 129 However, comprehensive and continually monitored public health strategies remain critical to maintain and reinforce declines in smoking prevalence. 129 As noted above, there are some countries for which the paradigm devised by Lopez et al in Figure 1.6 does not fit. This is especially so in nations in which female smoking rates have not shown a pattern of steady increase in Stage II, despite high prevalence among males, most likely due to social or cultural constraints. For example men in China and Indonesia have maintained high rates of smoking for many years, while female prevalence has remained in single digits. However the WHO model described above provides a useful framework into which many countries can be placed, and may enable countries currently at an earlier stage in the paradigm to recognise their situation, learn from international experience and introduce strong public health measures that will reduce the impact of tobacco on their population. Singapore provides a successful example of early intervention. In the early 1970s, while at stage two of the model, the Singaporean government initiated a series of tobacco control measures that capped smoking prevalence at a relatively low level, effectively averting the later stages of the epidemic. Thousands of tobacco-caused deaths in Singapore have been prevented as a result of this early, decisive action. 61 Tables 1.14 and 1.15 present statistics on smoking prevalence from a number of different countries. Table 1.14 shows prevalence data collected by the OECD (Organisation for Economic Co-operation and Development) of its 30 member countries, 136 and the data in Table 1.15 are taken from a wide variety of sources compiled by The Tobacco Atlas (Second Edition). 127 These tables are provided in order to provide a general global overview. It is important to note that data sets between countries are not directly comparable, due to differences in sampling and definitions, Figure 1.6 Four stages of the tobacco epidemic Source: Lopez et al 61 (Reproduced with permission from BMJ Publishing). Section: