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“Beware the investment activity that produces applause; the great moves are usually greeted by yawns.”
Warren Buffett
WHEN I tell people I’m a scientist and physician working on population health, they usually react with interest. When I tell them that one of my priorities is investigating the effects of smoking on health, the look of interest often changes to one of concerned sympathy, before they lean towards me and quietly break the news: “But it says it on the packet” – in the tone of voice reserved for a well meaning idiot who has totally missed the point. Overcoming my initial surprise – and checking that I’m not a complete idiot – I have come to realise that this attitude is part of a broader public health success. Everyone knows smoking is terrible for your health.
At the same time, there is a general air of boredom when smoking is mentioned. There are a number of reasons for this. First, as a community, we tend to underestimate the harms of smoking. Second, most people think that it is “solved” and increasingly irrelevant. Third, we think we know everything we need to know about smoking. Finally, the whole thing has dragged on for decades, without the kinds of exciting narratives, breakthroughs and punchlines that keep us engaged with a story.
Smoking remains our most deadly habit
Australia is a world leader in tobacco control. In 2016, an estimated 13% of adults in Australia smoked daily: incredible progress from the 1940s, when the majority of adult men smoked. Yet, smoking remains our single greatest cause of premature death and disability, accounting for 9% of the burden of disease, ahead of high body mass index, high blood pressure and alcohol.
Just as it is the greatest cause of burden of disease in the community, smoking remains a critical cause of ill health for individual smokers. The Sax Institute’s 45 and Up Study has shown that it is even more deadly for Australians that previously thought. Up to two-thirds of all current smokers in Australia will die from a smoking-related disease if they don’t quit, losing an average of 10 years of life expectancy, compared with people who have never smoked. Even smoking fewer than 14 cigarettes a day – previously considered “light smoking” – doubles the risk of dying prematurely; the equivalent of being morbidly obese compared with having a healthy weight.
Worldwide, there are around 1 billion current smokers. Smoking is responsible for more than 10% of all deaths, with 6.3 million deaths each year attributed to smoking. There were an estimated 100 million deaths from smoking in the 20th century. Over 1 billion deaths from smoking are expected in the 21st century if we continue on our current trajectory.
Smoking is not “solved”, even in Australia
It is clear that globally smoking is an appalling health problem. Despite extraordinary continuing suffering, massive declines in smoking prevalence, reductions in public smoking, stigmatisation and secrecy and increasing concentration of smoking in disadvantaged populations have contributed to a perception that smoking is largely “solved” in high income countries. This means that Australian policy makers and others with power and influence do not generally encounter smoking in their peers and day-to-day lives. However, there are still around 2.7 million current daily smokers in Australia. For Aboriginal and Torres Strait Islander people there have also been extraordinary drops in absolute prevalence of smoking – similar to or greater than those in the general population – meaning that around 41% of Aboriginal and Torres Strait Islander adults smoke daily.
Understanding smoking and its effects is critical to local and global efforts
Why research smoking? Isn’t it enough to know it is bad for you? The impact of smoking on health varies from population to population and over time. In the 1960s, when most smokers started later in life and had not been smoking heavily for prolonged periods, around one in six continuing smokers in countries such as the United Kingdom, the United States and Australia could expect to die from their habit. This increased to one in two in the 1980s and 1990s. This “one in two” figure was used by Australian tobacco control agencies up until the publication of large-scale contemporary findings from the 45 and Up Study, which found that up to two-thirds of all continuing current smokers in Australia would die from their habit if they did not quit.
This finding has had rapid uptake and is now used by most major government and non-government tobacco control agencies, including in support of recent tobacco excise legislation and in delivering front line advice to smokers contemplating quitting. The shift from a 50/50 chance of dying from smoking to an “odds on” probability, as well as findings highlighting the benefits of quitting are a powerful motivator: the 45 and Up Study found that quitting at any age was beneficial – the earlier the better. Research from the 45 and Up Study has demonstrated differential patterns of smoking behaviour in migrants and with acculturation, has shown increased risk of tooth loss in smokers, has provided evidence on methods for assessing lung cancer risk, and is currently contributing to burden of disease estimates for the Australian Institute of Health and Welfare.
Quitting smoking creates everyday heroes
We are conditioned to respond to narratives about individual efforts; heroes grappling with dangerous beasts and triumphing against the odds. But the true narrative about health and effective clinical practice is about long term persistence, including the granular efforts of individuals to quit, supported by their friends, family and health professionals. Clinicians and others working at the front line have played a critical role in tobacco control. There is clear evidence that brief interventions in primary care and by clinicians in other settings are effective in reducing smoking (here and here). In common with multiple organisations internationally, guidelines on cessation published by the Royal Australian College of General Practitioners recommend the “5As” approach:
- asking and recording details about smoking status;
- assessing a smoker’s readiness to change;
- advising smokers of the importance of quitting in a clear and supportive way;
- assisting smokers to quit, based on their readiness and individual needs; and
- arranging follow-up to support sustained efforts to quit and remain abstinent.
The fact that smoking will kill the majority of people who continue to do it long term (and according to the manufacturers’ instructions) means that supporting one person to quit is likely to be life-saving. The worldwide impact of improved tobacco control includes the potential to save 6.3 million lives a year, with commensurate reductions in illness and disability and virtually no side effects – and multiple additional system-wide economic, environmental and social benefits. Embracing this narrative recognises those who are part of tobacco control as the everyday heroes they truly are.
Professor Emily Banks is a Senior Advisor at the Sax Institute and lead of Epidemiology for Policy and Practice at the National Centre for Epidemiology and Population Health, Australian National University.
Smoking is a physical and visual “Relaxation Exercise” with short term relief of stress. Smokers know this.
Nicotine has an adverse longer term effect on mood that is greater than this “benefit”. Smokers don’t know this. They are being “tricked”. They don’t know this either.
Explaining this apparent paradox to them often provides added incentive to quit.
We could add ryme, rhythm and melody for extra persusion if someone could write some music to my song (below) and a band could sing it. Any takers?
THE SMOKER
CHORUS; See me smoking, I’m so cool!
Am I really such a fool?
Experts say I should not smoke.
They of course are clever folk.
But not so clever, they can’t see
Smoking may be good for me.
CHORUS
My stress feels less, I make a flame,
Breathing slow, relaxed again.
Make another lovely cloud.
Feel at peace, one of the crowd.
CHORUS
So I think that stress goes low?
Fool I am that does not know!
Nicotine goes to the brain
And raises stress right up again.
CHORUS
The peace I get from every puff
Doesn’t lastnear long enough.
Nicotine inside my head
Has made the stresses worse instead.
CHORUS
A moment’s pleasure, then again
Increasing stress and long-term pain.
The companies do laugh and drool.
As once again I am their fool.
CHORUS
Well regarding comments by Anonymous, if that is true that Au tobacco is having residual effects as compared with overseas tobacco that could be great legal implication for selling it to general public. No one is allowed to sell out of date products and toxic ingridients added to tobacco. I belive that is just a metter of time when Au smokers wiull ask for legal protection or ‘guit or die’…… Interesting
Doctors and Nurses are probably more aware of the power of a human beings emotions to affect outcomes than most. The patients ability to have a great outcome, or a terrible one, dependent on emotional state is so often quite obvious. When in a stroke ward years ago I could have foretold which of the six of us would have the best recovery and which would not based on what Bruin Bruin describes in her comment As the ‘feeling and emotional mind’ response in each individual.
That same ‘feeling and emotional mind’ has a powerful ability to either produce good or bad results when it comes to quitting smoking. Most people achieve success in that only when their emotions are aligned with their will or intent.
Neuroscience has shown us the mind/brain/heart connection is a strong influencer and that that each of us as individuals have have the capacity to influence our outcomes by dealing with that ‘feeling and emotional mind’. Hypnosis is a good way to deal with the reasons that sometimes emotions block a desired result. Since 2004, in my practice many smokers have been able to lead healthier lives because of Hypnosis.
Yes, I’ve heard this statement previously. ‘Tobacco smoking is the leading cause of preventable disease and death, in Australia’. One wonders what it is that is done to Australian tobacco, as different from tobacco of other nations that makes it so lethal. I’m not a smoker, per se. But I have done, and not with any regularity. I’ve smoked tobacco from Australia, as well as that from overseas. Many overseas tobacco brands do not leave any residual aftertaste effects, let alone make you feel as though one might need an artificial lung to see out the afternoon, as some Australian tobacco brands do. Some acquaintances I know who are foreign nationals to Australia are quite open in regards their condemnation of Australian tobacco. Makes one wonder…
complacency = recalcitrant denial of the value of tobacco harm reduction strategies. The old guard is clearly still in control.
Unfortunately smoking cessation has flatlined in Australia, and in some states there are actually more people smoking. The UK and USA are seeing people quit at increasing rates thanks to Tobacco Harm Reduction (THR) measures such as encouraging the use of safer E-Cigarettes. Japan is seeing huge shifts from burnt tobacco to safer Heat Not Burn tobacco products.
Australia however is determined that smokers must, ‘quit or die’. Mostly due to out of touch and out of date tobacco control dinosaurs, who think that everything is a plot by big tobacco.
Countries which have legalised and support vaping as tobacco harm reduction are seeing far greater quit rates than Australia. Public Health England has twice affirmed that vaping is at least 95% less harmful than smoking. But here public health prefers to wring its hands rather than support useful action.
Improved therapy includes the potential to save 6.3 million lives a year, with commensurate reductions in illness and disability and no side effects.
1. Asking and recording details about smoking status; is an upfront record taking.
2. Assessing a smoker’s readiness to change; relies on the ‘conscious mind’ answer, but is often not a true answer as we have an internal ‘feeling and emotional mind’ that may disagree with the first answer.
3. Advising smokers of the importance of quitting in a clear and supportive way; most smokers already know that and many have already tried to stop in varying different ways without success.
4. Assisting smokers to quit, based on their readiness and individual needs; I have not heard of one case where the patients life background of childhood or adult traumatic happenings have been addressed to facilitate this. In fact most ‘cognitive’ therapy looks at only looking forward with no need to deal with the past – a grave mistake.
5. Arranging follow-up to support sustained efforts to quit and remain abstinent; You shouldn’t have the need to do this if they had stopped smoking with; No willpower… No craving… And just not wanting to smoke anymore. yes, you should check that they have stopped smoking. If they haven’t, what you have done, isn’t working.
6. If you are relying on medication to assist, you have clients with side effects. If they are still smoking after having been weaned off smoking but they still have craving – you have missed a crucial reason of finding out what emotion(s) smoking is helping your patient cope with (known or unknown). Blaming a patient for not stopping – the excuse of some therapists who say that the client just doesn’t want to – is shifting your responsibility of why that is – on to the patient. I have been helping people to stop smoking since 1992 and they usually stop smoking in a 2 hour session. Unfortunately doctors do not have the time to do what I do, nor the expertise in hypnosis, but they do have the ability to on-refer to people that are able to make the changes for the patient.
If they on-refer but the referral outcome was unsuccessful, I would suggest you find another person to refer to that has the expertise to be successful in this area.
You can validate this here: https://www.bbbenefits.com.au/client-testimonials/
If you were truly interested in reducing the damaging effects of smoking, you should have discussed tobacco harm reduction. None of the ‘narratives’ mentioned in this piece had any effect on my 29 year smoking habit. I’d have died as a smoker if I had not discovered vaping (zero thanks to the ‘everyday heroes’ of tobacco control).
A ban on smoking in all public places can’t come soon enough!
North Sydney Council’s courageous ban on smoking in their CBD is encouraging.
Thank you, Emily for your continued life-saving research!
The negative health effects of smoking extends beyond smokers themselves to those who are in the realm of their exhaled cigarette smoke.
I’ve been asthmatic for 55 years.
During my daily pedestrian commute to work/home in the Sydney CBD my eyes are constanly focused on the hands of oncoming pedestrians. As soon as I see a person walking towards me with a cigarette in their hand I cover my nose and mouth to prevent inhalation of their exhaled cigarette smoke. If a don’t see a smoker approaching or am too slow to “cover up” I start wheezing and experience breathing difficulty immediately the cigarette smoke enters my lungs. Additionally, if I approach someone from behind who is smoking a cigarette, I have to either cross the road or, if that isn’t practical, drop back more than 20m so that I don’t inhale from the trail of cigarette smoke attached to the smoker.
Having to endure the ill-effects of exhaled cigarette smoke in public places is simply unfair and plain wrong!
Good work Professor Banks. As you have said before “Smoking is the new Smoking”. We do not need another public health priority while this one continues to kill so many people both here and globally. You are one of the everyday heroes and we at Cancer Council Australia acknowledge your fabulous contribution.
Dear Emily, an excellent article. It is unfortunate that the ” magical ” side of human thinking makes it difficult to get the message
across, and we need to work out ways to penetrate this, and help people to expand their real insight. Ed