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ON 14 August, 2017, The Australian newspaper ran a story guaranteed to go viral. The headline screamed: “More smokers lighting up, despite the costs”. The journalist, Adam Creighton, who has, grotesquely, written about tobacco control being like Nazism, reported on a claim being made by Dr Colin Mendelsohn, “an expert in public health at the University of NSW”, that:
“an unexpected standstill in the national smoking rate since 2013, combined with rapid population growth, has pushed up the number of regular smokers by more than 21 000”.
The article said that Australia’s smoking rate was now higher than the United States’ rate for the first time in a decade.
“This is despite plain packaging and the most expensive cigarette prices in the world.”
The claim was covered widely across Australian media, with Dr Mendelsohn interviewed several times. Senator David Leyonhjelm issued a press release repeating the claim, which would have pleased his party’s tobacco industry donors.
I received enquiries from the US and England asking me if the claims were true. I immediately called fake news. Here’s the real story.
The Australian Institute of Health and Welfare (AIHW) surveys national smoking prevalence every 3 years as part of its National Drug Strategy Household Survey. We also have annual data from England and the US on smoking rates with which we can compare Australia’s progress.
In 2013, there were 16.4% of Australians aged 18 years and over who smoked. By 2016, this number had fallen to 15.7%. By contrast, the US rate for 2016 is 15.8%, a sliver higher than Australia’s 2016 rate. England’s rate in 2016, according to the long running Opinions and Lifestyle Survey, was 15.8%, again marginally higher than Australia’s.
So, if anything, the smoking rate in Australia is identical to or marginally lower than in the US and England in 2016.
Australia’s fall from 16.4% in 2013 to 15.7% in 2016 was not statistically significant. Dr Mendelsohn has stated publicly that Australia’s historically continual fall in smoking has therefore “flatlined”. This is an interesting claim because any student of statistics knows that while you can always draw a line between two points, you need a bare minimum of three data points to determine a trend line, including a flatline.
Dr Mendelsohn is an enthusiastic proponent of e-cigarettes and appears to be using international comparisons to justify a call for making these more available in Australia.
In the US, smoking actually increased from 15.1% in 2015 (the figure that Dr Mendelsohn was citing) to 15.8% in 2016, despite (or perhaps partly because of) the nation being awash with e-cigarettes. But like Australia’s statistically insignificant fall in smoking, the rise in smoking in the US was also not statistically significant (see figure 8.1 here).
If Australian smoking has flatlined, consistency would demand that we also say the same of the US, which doesn’t yet appear to have been done.
And what about the extra 21 000 smokers estimated? The figure of 21 000 can be found nowhere in the AIHW tables of figures. No nation reports its progress against smoking by quoting changes in the total number of smokers: the universal practice is to report rates (ie, percentages of the population).
There were about 2.4 million smokers in Australia in 1945 (when 72% of men and 26% of women smoked) – in a population of 7.5 million. This is about the same as the number of smokers in the population today. If we are to look only at the actual number of smokers, some might argue that we have therefore achieved nothing in 70 years, despite smoking prevalence today being 15.7% (or 12.8% if daily smoking is the measure).
Dr Mendelsohn appears to have arrived at a figure of 21 000 extra smokers by multiplying the percentage of daily smokers listed for each year in Table 3 of the AIHW report, with an estimate of population numbers of Australians 18 years and over in June 2013 and 2016 released by the Australian Bureau of Statistics in June 2017. These population estimates were published some months after the AIHW would have undertaken the analysis of smoking prevalence for 2016 and some years after it released its estimate of prevalence in 2013.
The estimate ignores the complexity of how survey results are weighted by population composition. It also ignores the fact that the prevalence figure is only an estimate, with margins of error. The AIHW’s table of relative standard errors and margins of error indicates that the prevalence of daily smoking among people aged 18 years and over in 2016 was somewhere between 12.2% and 13.4%. This means that the number of smokers in 2016 could have been anywhere between 2 293 000 and 2 512 000. A similar range applies to the figure for 2013. The calculation of an extra 21 000 smokers between 2013-2016 is therefore essentially meaningless.
Moreover, the Australian Bureau of Statistics population figures show that between 2013 and 2016, Australia’s population aged 18 years and over grew by 864 340 people as a result of births, deaths and immigration. Many immigrants in this number would be from nations where smoking rates are high, particularly among men.
The elephant in the room? Massive growth in never smokers from smoking prevention.
Media attention has focused on smokers. But applying the same calculation Dr Mendelsohn has done for current smokers to people in the rest of the population, one would conclude that there are more than 870 000 extra non-smokers in Australia in 2016 than there were in 2013 — more than 80 times the number of extra current smokers (and more than 40 times the number of extra daily smokers) that he is so concerned about.
The impact of policies such as tobacco tax, plain packs and graphic health warnings is not just judged on smoker numbers, but on quitters and most importantly, in terms of prevention; the proportion of the population who have never smoked. The Australian National Drug Strategy Household Survey reported a significant decline in the percentage of young people smoking and a significant increase overall in the proportion of people who have never smoked — see the # symbols on Table 3 in the spreadsheet here. These figures indicate substantial achievements.
The article in The Australian declared “Australia’s punitive and coercive policies have run out of steam”. I assume this refers to successive Australian governments’ tobacco tax increases. The first of these increases in 2010 saw the CEO of British American Tobacco Australia, David Crow, telling a Senate committee in 2011:
“We understand that the price going up when the excise goes up reduces consumption. We saw that last year very effectively with the increase in excise. There was a 25 per cent increase in the excise and we saw the volumes go down by about 10.2 per cent; there was about a 10.2 per cent reduction in the industry last year in Australia.”
These are the same tax increases that a coalition of New Zealand experts announced very recently that they want their country to adopt, emulating Australia.
The government’s recent mid-term report on its National Tobacco Strategy has also highlighted the need to improve cessation rates, but it has also provided an overwhelmingly positive picture of progress in Australia — see table 1 in the detailed report here.
We’d all like to see smoking prevalence fall even faster than it currently is. But to argue that we are going backwards or stalling is simply wrong.
Simon Chapman, AO, is Emeritus Professor of Public Health at the University of Sydney.
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‘We’d all like to see smoking prevalence fall even faster than it currently is.’ That is apart from the current government that is relying so heavily on the tax dollars raised by the ‘life saving’ techniques they have adopted to pay for infrastructure election promises. If we became a smoke free society, perhaps then the gov’t may have to turn its attention further onto the known carcinogen ethanol and treat every Aussie drinker as a leper and shun them from the squeaky clean self indulged image these politicians believe they are. I have tried almost every quit style of aid pills, patches, gum, lozenges, hypnotherapy etc etc.. etc….. etc. Not a single one has had the clear minded, absolute confidence and knowledge I will never smoke filth again. And have seen my recommendations save lifes (and i don’t use that term lightly as gov’t seem to) and give hope and power back into the hands of several people who have struggled to give the filth the boot for decades. I don’t care that there may be long term risks associated with vaping as anyone with half a brain still attached to their spinal cord can plainly see the lack of those carcinogens that are just chock a block in ciggies are no longer entering me anymore. And if these politicians still had their spinal cords they might be able to look further than their current term in power and acknowledge the lives they would save over the collection of the tax dollar being more important. But sadly cant see that happening.
Quit claims and harm reduction claims by consumers and medicos are completely legitimate if they are not trying to sell anything. It is only claims by suppliers that are problematic legally if they are untrue and unproven and should not happen. So I guess we sort of agree but I’d add that making such a fuss about it merely distracts from the important matters like reducing death and disability from sucking in burning matter. Report them to the ACCC, job done.
People do all sorts of things that are not good for them but we don’t medicalise alternatives that are less harmful and just plain good ideas that work. An obese person that has a medical procedure such as gastric banding surgery to stop them overeating is completely different to that same person eating less and more healthily and exercising more. The first should be highly regulated as a medical intervention, the second though shouldn’t and isn’t. Both though may/will cause weight loss and less morbidity and mortality at a population level.
In terms of vaping, there is no reason why those suppliers that make quit or therapeutic claims have their products up for approval by the TGA. I don’t think anyone has a problem with that and for those smokers that wish to see themselves as needing a therapeutic intervention, could and should buy these products if that is their desire. I think we agree on this.
However, those that wish to continue inhaling nicotine as a substitute for inhaling burnt tobacco should be entitled to do so under consumer law legally. This is harm reduction and the consequence for many millions is that they no longer smoke. Should a supplier not make quit claims, their products should not require TGA approval because it’s not a medical intervention just as improving one’s diet isn’t.
I might be wrong but you appear to be annoyed with us vaper advocates and many medicos making quit success claims along with harm reduction as a consequence of smokers switching to vaping. This is not an oxymoron. I switched from smoking to vaping and as a consequence I quit smoking completely. I became the beneficiary of both inhaling nicotine in a harm reduced way and I also quit smoking. It was all the therapeutic products and medical interventions that saw me continue smoking, unlike vaping.
There is an absolute middle ground which supports common sense regulation of vaping and I think you know it. The ACCC have already shown that they are willing and able to deal with false claims and illegal practices in the e-cigarette sector as a consumer product. In fact, most vaper advocates are expressing their desire that the current consumer laws should be strengthened when nicotine is legalised, not lessened to include age restrictions, quality assurance, labeling & packaging requirements etc. This does not prohibit the TGA regulating those suppliers that make therapeutic claims. I think I’ve seen it written as ‘dual pathway’ regulation.
The facts of the matter are that vaping is happening now in Australia with nicotine supplied on the black market or imported from overseas. You can’t stop it but you can contribute to sensible consumer regulations (or dual pathway regulations) that will see many people that are unwilling or unable to quit smoking, have the opportunity switch to far safer vaping legally with more safeguards in place than currently exist.
Donna — NRT has had TGA approval for nearly 30 years, and yet the long-term success of NRT without professional support (ie 99.99% of its real world use) is about 5%. That is a very, very low bar for any applicant to jump over in providing evidence for efficacy in cessation ti the TGA. So what’s the problem? Why are they so shy in coming forward? Do they know something they’s rather not have interrogated by the TGA evidence assessment standards?
Please don’t get me going on vaping being “an activity”. You can’t read any vaping blog, submission to parliament or hear a vaper in the media who doesn’t talk immediately about therapeutic claims (ie how good they allegedly are for cessation). You can’t walk on both sides of the street on this. Any product making therapeutic claims needs to be regulated by the TGA.
I agree that the most likely applicants able to get TGA applications to the required standard are large companies with research resources and quality assurance standards. That’s GOOD, surely? If you heard someone spruiking a cancer, AIDS or asthma cure, saying that they mixed up the broth in their backyard or kitchen lab, and making claims about a billion lives being at stake and, hey, this is all too important to be constrained by bureauracy and regulatory red tape, woukd you be out on the hustings demanding that the TGA stay out of it? Let some importer sell and advertise his snake oil because gee, cancer is really bad? No one reasonable would. Yet this is what vaping advocates want to see happen with ecigs.
Your argument about “deadly cigarettes are not regulated, so ecigs shoud not be either” is completely the wrong way round. The hundreds of millions of lives we have lost from unregulated cigarettes is precsely because governments have resisted regulating them for so long. As you know, I have spent my entire career advocating for advertsinng bans, graphic health warnings, smoke free laws, retail display bans, plain packs, big tax rises, campaign financing. I also applaud the recent US FDA near-to-zero nicotine announcement and their planned FDA regulation of ecigs. But most leading ecig advocates want none of these things for ecigs. That’s perverse IMHO. (although entirely predictable given the many parties who are just in all this for the money).
I haven’t ever advocated for “harm reduction” regulatory standards for cigarettes because everyone knows that combusted cigarettes of an acceptable health standard are an oxymoron. I also haven’t advocated for cigarettes to be banned as I see such heroics frankly as political idiocy.
Simon, you and I both know that TGA regulation is prohibition by another name. The TGA have had one product put before it and refused to even assess it. Vaping works because the smoker can use what is right for them in terms of flavour, power, price, nicotine level and aesthetics. Get 1000 vapers in a room and you’d be hard pressed to find two that use identical products. This is why it works.
Why not let a much safer product compete fairly and squarely with its deadly competitor in the same product category ie. consumer products? It’s perverse that you are calling for strict TGA regulation on the far safer product and not on ‘tobacco prepared and packed for smoking’ which is currently excluded.
You are putting smokers and vapers at the mercy of multi national Tobacco and Pharma companies who are the only ones with the money to afford the TGA process and will only get ineffective vanilla products assessed. Considering their refusal to assess so far, this option is not even possible now. Not to mention the fact that it appears no Tobacco or Pharma company is knocking down the doors of the TGA saying ‘please approve our product’.
Basically you are saying to smokers and vapers; if big business decide to spend millions of dollars and go through the onerous TGA process, we’ll let you use the far safer product. Until this happens, keep on smoking.
Smoking is an activity, not a disease and vaping happens to be a far, far safer way of enjoying the same activity. If smoking is not medicalised, vaping certainly shouldn’t be.
Thomas, “Simon’s prohibition”? This is not my position at all. Please read my submission (with three others) to the current government enquiry https://t.co/KnuxV6Y5EQ and you will see that I strongly support regulation of ecigs through the TGA. If the TGA decided that applications did not satisfy criteria of safety and efficacy, I would have every confidence in that process. They make decisions on many therapeutic devices every year. Also, you say that the number of smokers can only reduce by “current smokers dying”. That leaves the small problem of the 22.8% of Australians >18 who once smoked, now don’t and are still alive to be explained. (ex-smokers) Very, very few of them stopped smoking by using ecigarettes, as our submission explains.
“Massive growth in never smokers from smoking prevention” This is a point that’s often missed in the argument, the lack of new smokers creating a low prevalence number. This is the best, possibly only way to achieve a smoke-free society. However, it only works by current smokers dying. It seems Simon is quite happy to use this attrition method to achieve his aim.
As there is no evidence e-cigs affect the number of new smokers, I see no reason to restrict them as they offer current smokers an exit other than death. A smoke-free society without the toll of death and suffering that Simons prohibition entails.
How ironic that Simon Chapman should author an article with ‘Fake News’ in the title, when he himself has deliberately propagated the myth that e-cigarettes only helped 16,000 people to quit smoking in the UK in a particular year by repeatedly misrepresenting Robert West’s paper on the subject.
In any case, as Robert West commented in response:
“Even if [Chapman] had got it right, to write off saving many thousands of lives as trivial seems pretty scandalous from a public health advocate”
Well, if current policies are deemed insufficient, I expect The Australian called for more drastic measures?
I’d suggest that we simply ban the sale of all tobacco products in Australia, and offer quit support for the remaining smokers. Much easier to stop if everyone else does, too. Just set the date.
Didn’t read the article, but I guess The Australian suggested no such thing. Pity.
Thisnis a very thorough analysis Simon – thank you for clarifying matters.