Impact

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Impact


The effects of tobacco use extend much further than the health impact on the individual. Tobacco use is responsible for a significant economic and social burden on society as a whole. In terms of overall impact, smoking remains the largest cause of both the human and economic cost of preventable disease in Australia. The social and economic burden of tobacco use is inequitably distributed, being carried disproportionately by already disadvantaged Australians.

A study led by the International Agency for Research on Cancer (IARC) looked at the impact of tobacco smoking on life expectancy in 63 countries and found that life expectancy would increase on average by 2.4 years in men and 1 year in women if smoking-related deaths were eliminated[1]. This study found tobacco smoking was related to 20% of total adult mortality[1].

The health impacts of tobacco use on the individual are considerable: An Australian study found that two of every three deaths in current smokers can be directly attributed to smoking[2]. Previous international estimates had put this figure at one in two deaths in long-term smokers[3]. On average, current smokers die 10 years earlier than non-smokers[2].

The health impacts of tobacco use are wide ranging. Tobacco use is associated with cancer, chronic respiratory illnesses and cardiovascular disease. Smoking causes almost as many cardiovascular related deaths as lung cancer deaths[4].

Tobacco is the single most common preventable cause of cancer burden in Australia[5] a further 15 cancer types[6]. In many Western countries, a third of all cancer deaths are caused by smoking; no other preventable risk factor has caused anywhere near the same level of cancer death and disease[7]. The World Health Organization project that, in 2015, tobacco will be responsible for 10% of all deaths globally[8].

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Impact of tobacco on cancer

Tobacco smoking is the single largest cause of preventable cancer mortality and morbidity in Australia, accounting for an estimated 22% of the nation’s cancer disease burden in 2011[5]. Smoking was attributable for an estimated 11,308 new cases of cancer and 8,155 cancer deaths in 2005[9]. A more recent study estimated 15,525 (13%) cancers in Australia in 2010 were attributable to tobacco smoke[10].

Of all the specific diseases associated with tobacco, lung cancer accounts for the largest proportion of tobacco-related disease burden in Australia[5] other conditions, lung cancer alone accounts for more than a third (35%) of the overall tobacco-related burden of disease in Australia[4]. It has been estimated that active smoking is responsible for 88% of all lung cancer deaths in men over 35, and 75% in women of the same age in Australia[11].

In 2005 (the most recent national data), there were an estimated 11,308 new cancer cases (11% of all new cases of cancer) and 8,155 deaths from cancer (nearly 21% of all cancer deaths) in Australia attributed to smoking[9].

A more recent Australian study estimated that 15,252 (13%) of cancers in Australian adults in 2010 could be attributed to tobacco smoking[10]. The largest numbers and highest proportion of cancers attributable to tobacco smoking were lung cancers with 8,324 (81%) cancers diagnosed. Of these, 136 lung cancers in non-smokers were attributable to partner tobacco smoke[10]. See Table 1 for a summary of the population attributable fractions of different cancer types attributable to tobacco smoking in Australia.


Table 1. Population attributable fraction (PAF) for males and females and estimated number of cancers diagnosed in Australia in 2010 attributable to tobacco smoking

Site Males Females Total number of cancers
Lung 84 74 8,324
Larynx 77 74 478
Oral/pharynx 65 45 1,973
Oesophagus 59 61 855
Bladder 34 26 781
Kidney & ureter 26 11 633
Liver 24 11 290
Pancreas 24 23 622
Stomach 23 11 383
Myeloid leukaemia 16 4 153
Bowel 6 7 951
Cervix - 7 56
Ovary - 17 26
All cancers 10 16 15,525

Source: Pandeya 2015[10]


The Link between tobacco and cancer section of this chapter has information on the evidence for the link between tobacco use and specific cancers.

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Broader health impacts

Tobacco was responsible for 11.7% of deaths in Australia in 2003[4]. In that year, 15,511 deaths were attributed to smoking[4]. The burden of disease caused by tobacco is disproportionately carried by males. Tobacco caused 9.9% of the total burden of disease and injury in males, compared to 5.8% in females[4].

Of all preventable risk factors, tobacco causes the highest proportion of Australia’s burden of disease and injury (7.8% of the total) – with lung cancer, chronic obstructive pulmonary disease (emphysema) and ischaemic heart disease accounting for more than three-quarters of the burden[4]. Sixteen tumour types overall, and cardiovascular disease, including stroke, also contribute to tobacco disease burden.

Second to cancer, the largest health impact of tobacco use is cardiovascular disease[4]. There is evidence that cardiovascular disease is a consequence not only of tobacco smoking, but also of exposure to second-hand tobacco smoke[12].

Second-hand tobacco smoke

A study of 2004 data found that in one year, over 600,000 deaths worldwide were attributable to second-hand smoke, accounting for 1.0% of worldwide mortality. The majority (47%) of deaths from second-hand smoke occurred in women, 28% in children, and 26% in men[13].

In Australia, the proportion of dependent children exposed to tobacco smoke inside the home has decreased over time, with only 3.7% of adults in households with children reporting smoking inside the home in 2013, steadily declining from 31% in 1995[14].

It was estimated that in 2004-05, 113 adults deaths in Australia were due to exposure to second-hand smoke and 56 deaths in infants were due to maternal smoking[15].

Maternal smoking, before and after birth

Antenatal and postnatal exposure to tobacco smoke have both been shown to contribute to a range of health problems in infants, including[16]:

  • low birth-weight
  • reduced lung function
  • spontaneous abortion
  • ectopic pregnancy
  • birth defects.

The 2002 United States Linked Birth/Infant Death Data Set reported that smoking in pregnancy was one of the most prevalent, preventable causes of infant death and illness[17].

Maternal smoking also has negative effects on the quality and quantity of breast milk[16].

In 2010, 11.7% of Australian women reported smoking during some or all of their pregnancy. In the period before they knew they were pregnant, 11.7% of pregnant women smoked and 7.7% smoked after they knew they were pregnant[18]. Data from 2008 shows the likelihood of smoking during pregnancy was higher among teenagers, women in disadvantaged circumstances and Indigenous women[19].

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Economic burden

Smoking is the largest preventable cause of both the human and economic cost of preventable disease in Australia – particularly in relation to cancer.

Smoking imposes a heavy financial burden on the Australian community – estimated at $31.5 billion in ‘social costs’ in 2004-05 (accounting for 56.2% of the total cost of legal and illegal drug use)[15]. Social costs include costs borne by the entire community, rather than private costs incurred and paid for voluntarily by tobacco users.

The social costs of smoking in 2004-05 included $318.4 million in health care costs, $249.3 million borne by the government with the remainder by businesses and individuals[15].

Conservative estimates from an earlier Australian study found that hospital costs alone attributable to smoking equalled $682 million for 2001-02, due to 300,000 hospitalisations and 1.47 million bed days[20].

Tobacco use is a risk factor for 16 cancer types (see the Link section of this chapter). For lung cancer alone, health expenditure in Australia in 2008-09 was $210 million[21].

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Prevalence of smoking in Australia

According to the 2013 National Drug Strategy Household Survey, in 2013, 12.8% of Australians aged 14 years or older smoked daily[14]. In 2011-12, there were 2.8 million Australian adults (16.3%) aged 18 years and over who smoked daily[22].

The proportion of people smoking daily has declined significantly over time. Daily smoking declined between 2010 and 2013 (from 15.1% to 12.8%) and almost halved since 1991 (24.3%)[14]. The average number of cigarettes smoked per week has also reduced, from 111 cigarettes in 2010 to 96 in 2013[14].

Smoking is more prevalent in men (20.2% men were smokers compared 16.3% women) and women are more likely to have never smoked than men (61.8% of women compared to 53.7% of men)[18].

According to the 2010 National Drug Strategy Household Survey report, just under one-quarter of the population (24.1%) were estimated to be ex-smokers and more than half (57.8%) had never smoked in their life in 2010[18].

State by state, smoking rates vary considerably. In 2010, the ACT had the lowest daily smoking prevalence of the states and territories (11% of people aged 14 years and over were current smokers), while the NT had the highest (22.3%)[18]. See Table 2 for the proportion of daily smokers by state and territory.


Table 2. Percentage of people 14 years or older who are daily smokers, by state/territory

State NSW Vic Qld WA SA Tas ACT NT Australia
% daily smokers 14.2 14.9 16.7 15.6 15.0 15.9 11.0 22.3 15.1

Source: AIHW 2011[18]

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Children and adolescents

More than 80% of smokers become addicted to nicotine as teenagers[23][24]. According to the 2013 National Drug Strategy Household Survey, younger people are delaying the take up of smoking. The age at which 14–24-year-olds smoked their first full cigarette increased from 14.2 in 1995 to 15.9 years in 2013[14].

National surveys of smoking among secondary school students have been conducted since 1984, using an anonymous questionnaire. The latest survey show smoking prevalence among teenagers has fallen dramatically in recent years[25]. In 2011, the proportion of students who were current smokers (had smoked in the last week) ranged between 1.3% among 12 year olds to 14.5% among 17 year olds, while overall 23.3% of students had some experience with smoking[25]. Only 3.6% of all students over all had smoked on three or more days in the previous week, with this proportion increasing to 8.6% among 17 year olds[25]. Between 1984 and 2011, the percentage of secondary school students who have never smoked has more than doubled, from 30.6% to 76.7%[26].

The 2011-12 Australian Health Survey reported that 4.4% of teens aged 15-17 years were daily smokers. However, it was noted that due to the data collection methods of the survey, the reported number might be an underestimate[22].

Similarly, the 2013 National Drug Strategy Household Survey reported that 95% of 12–17 year olds had never smoked in 2013, and the proportion of 18–24 year olds who had never smoked increased significantly between 2010 and 2013 (from 72% to 77%)[14]. The survey is a household-based self-reporting survey and it has been noted that self-reported rates of smoking in adolescents may be underestimates[27].

One Victorian study in 12 to 15-year-old children indicated significantly higher rates of smoking. The study found that rates of current and ever tobacco use are higher in rural teens than urban teens – 49.6% in rural compared to 37.4% in urban for ever smoking, 16.8% compared to 11.2% current smoking[28].

Indigenous Australians

Aboriginal and Torres Strait Islander people aged 15 years and over are 2.6 times more likely than non-Indigenous Australian to be current daily smokers (after adjusting for differences in age structure between the two populations)[29].

In the 2012–13 Australian Aboriginal and Torres Strait Islander Health Survey, 42% of Indigenous Australians over the age of 15 were current daily smokers. Rates have declined since 2002, when the rate of daily smokers was 49%[29]. One in five Indigenous adults were ex-smokers, an increase from 15% in 2002, and 37% of those surveyed had never smoked[30].

Indigenous Australians living in remote areas are more likely to be current daily smokers than those living in major cities (50% and 39%, respectively)[29]. Despite decreasing rates of smoking in Indigenous people from 1994–2008, the rates of smoking for Indigenous women in remote areas have not[30][31]. There is some evidence they have increased[31].

In 2008, four in 10 young Indigenous Australians (aged 15–24 years) were current daily smokers, more than twice the rate for non-Indigenous young people (16%)[32]. Among young people aged 15–17 years, the proportion who had never smoked increased from 61% in 2002 to 77% in 2012–13, and for those aged 18–24 years, increased from 34% to 42% over the same period[29].

Close to two thirds of Indigenous children (65%) are exposed to environmental tobacco smoke compared with less than one third of non-Indigenous children (32%). Indigenous children are also three times more likely to live in households with a regular smoker who smoked indoors at home[32].

Culturally and linguistically diverse Australians

Overall in Australia, smoking rates among people whose main language is not English are lower than the average. In 2010, people whose main language at home was not English had a smoking rate of 11.6%, compared to 18.4% of people whose main language was English. There were a high proportion of non-smokers in homes where English was not the main language spoken (80.4%), compared to predominantly English-speaking households (55.5%)[18]. The National Health Survey reports similar findings, where prevalence of smoking was 12.2% among those who predominantly speak a language other than English[33]. These findings should be interpreted with caution as non English speakers are under-represented in this survey.

Despite lower rates over all, smoking is more prevalent among a number of specific cultural, ethnic and socio-economic groups, resulting in these groups bearing a disproportionate share of Australia’s tobacco-related disease burden. A number of older studies have indicated that among the Arab-speaking population in Sydney, more than 50% of both males and females smoked[34], and among the Sydney-based Lebanese community about 49% of males and 29% of females were smokers[35]. Male members of the Vietnamese community in Sydney had smoking rates of 53%[36].

Disadvantaged groups

Smoking rates among a number of disadvantaged groups are much higher than in the general population. Smoking rates across Australia have declined substantially to around 17.5% of adults smoking weekly or more often[18]. However, among the most disadvantaged groups smoking rates are significantly higher than the population average.

Across the population, smoking rates are associated with socioeconomic status: the proportion of smokers in the lowest socioeconomic status tier (24.6%) is almost double that of the highest (12.5%)[18].

A number of populations experiencing disadvantage have higher than average smoking rates: single parents (37%)[18], lone mothers 18–29 years of age (59%)[37], people living with psychosis (66%)[38], adults with mental illness (36%)[39], at-risk young people (63%)[40], people with drug disorders (73%)[39], the homeless (73%)[41], intravenous drug users (90%)[42], prisoners (85%)[43], and those living in remote areas (28.9%)[18].

Due to the success of smoke-free environment policies (see the Effective interventions section of this chapter), smokers are now generally more inclined to opt to smoke outside the house when at home. However, exposure to environmental tobacco smoke remains high in disadvantaged groups such as children from low socioeconomic status groups[44].

See the Cancer Council Australia position statement on Smoking related disparities for more information.

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Prevalence of lung cancer in Australia

As previously discussed (see above), lung cancer is the primary health consequence of tobacco use. Lung cancer accounts for more than a third (35%) of the tobacco-related burden of disease in Australia[4]. Active smoking is responsible for 88% of all lung cancer deaths in men over 35, and 75% in women of the same age in Australia[11].

In 2014, there were 11,556 new cases of lung cancer diagnosed in Australia[45]. Lung cancer is more common in males, with 6,695 incident cases being diagnosed in men[45].

The prognosis for lung cancer is poor. The five-year relative survival for people diagnosed with lung cancer (compared to the general population) is 14.1% (12.6% for males and 16.5% for females)[46]. Although lung cancer is the fifth most commonly diagnosed cancer in Australia, it is the most common cause of cancer death in both males and females, responsible for 8,466 deaths in 2015[47][45].

Female smokers in Australia appear to have about twice the risk of dying from lung cancer compared with male smokers. Women who smoke face a 20-fold increased risk of death compared to nonsmokers, in comparison to a 10-fold increase in males[48].

Lung cancer trends

Lung cancer incidence in Australian men is in relative decline, yet in women the disease recently exceeded breast cancer as the number one cause of cancer death[47]. The incidence of lung cancer is projected to decrease to 49.3 per 100,000 in males in 2020, down from 55.4 in 2011[49]. However, incidence rate in women is expected to increase to 36.2 per 100,000 in 2020 from 32.4 in 2011[49].

This variation in trends is probably due to different tobacco consumption histories: reductions in smoking among men in the second half of the 20th century have subsequently been reflected in declining male lung cancer rates, with a time lapse of about 20 years. Cigarette smoking in Australian women peaked later than in men, which is thought to explain the rising incidence and mortality of female lung cancer[47][11].

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