Smoking is the new smoking

When I was asked to write this article, the title suggested to me was ‘Sitting is the new smoking’. As an epidemiologist and public health physician working across multiple factors that influence cardiovascular disease (CVD) risk, I disagreed with this title and suggested the current one, ‘Smoking is the new smoking’. We do not need a new smoking – the old one will do just fine. 

I then pondered why there is a need for a ‘new’ smoking and why emerging risk factors are considered to be comparable with smoking. I concluded that this is chiefly the result of:

• underestimating the current impact of smoking on health
• thinking that the problem of smoking has largely been ‘solved’, especially in relatively wealthy countries
• regarding smoking as a boring and old issue.

Smoking is important

The impact of smoking on CVD and mortality is large and often underestimated. Of all the current behavioural risk factors, nothing compares with smoking in terms of individual risk. Up to two-thirds of current smokers in Australia will die from a condition caused by their smoking if they do not quit, with an average 10-year loss of life expectancy compared with someone who has never smoked.¹ Even smoking less than 14 cigarettes a day – previously considered to be ‘light smoking’ – doubles the risk of dying prematurely;¹ this is the equivalent of being morbidly obese compared with having a healthy weight.² Being a current smoker more than doubles the risk of dying of ischaemic heart disease and confers an even greater relative risk the younger the person is.³ This means that death from a heart attack in a smoker is more likely than not to have been caused by smoking. 

Sir Richard Doll, a pioneer in our understanding of the impact of tobacco on health, said ‘death in old age is inevitable but death before old age is not’, highlighting the importance of focusing on the impacts of smoking on premature illness and death.⁴ In Australia in 2004 to 2005, 40% of deaths due to ischaemic heart disease in men aged 35 to 39 years and 34% of deaths due to ischaemic heart disease in women aged 40 to 44 years were attributable to smoking.⁵ The figures for stroke are very similar.⁵ Smoking remains the single greatest risk factor contributing to the burden of disease in Australia, being responsible for 12% of the burden of illness due to CVD and death across a lifespan and 9% of the total burden of illness and death; high body mass index is estimated to be responsible for 5.5%.⁶ 

Worldwide, there are an estimated 6.3 million deaths per year from smoking – more than 10% of the total number of deaths.⁷ There were an estimated 100 million deaths from smoking in the 20th century. More than one billion deaths from smoking are expected in the 21st century if we continue on our current trajectory.

Underestimating the harms of smoking means we also underestimate the benefits of quitting. The decline in smoking prevalence to less than 15% of adults being current daily smokers in Australia, and similar declines in many high-income countries, represents an extraordinary achievement – for public health, clinical care and the individuals, families and communities who have benefited. This decline is a key contributor to the reduction in deaths from CVD in Australia by more than 80% since their peak in 1968. There are 43,000 deaths from CVD in Australia per year; however, there would be more than 200,000 per year had the peak rates continued. 

Smoking remains a key health challenge

There is a general perception that the smoking problem has been ‘solved’ in high-income countries. This is due to the massive decrease in smoking prevalence and, at least partly, because smoking is increasingly concentrated in the disadvantaged. Stigma means that people are often secretive about their smoking habits. Hence, policy makers and others with power and influence do not encounter smoking in their peers or day-to-day life. However, there are still about 2.7 million current daily smokers in Australia and about one billion current smokers worldwide. About 42% of Aboriginal and Torres Strait Islander adults smoke, although decreases in the absolute prevalence of smoking have been similar to those seen in the Australian general population. 

Smoking is not a boring issue

This year, I gave a presentation at the World Economic Forum in Switzerland as part of its increasing focus on health. In the midst of the excitement about nanotechnology, artificial intelligence and personalised medicine, I was informed that smoking was ‘a bit boring’, despite being the single largest readily preventable cause of illness, disability and premature death worldwide. Yet, imagine the reaction if I announced a novel and innovative intervention that would rapidly save 6.3 million lives a year, with commensurate reductions in illness and disability and almost no side effects, and multiple additional system-wide economic, environmental and social benefits. This is what prioritising tobacco control has to offer.

Saving lives: the crucial role of health professionals

Clinicians and others working at the front line continue to play a crucial role in tobacco control. For them, it is not possible to ignore the continuing toll of illness and premature death from smoking. Although smoking is highly addictive and cessation often requires multiple attempts, there is clear evidence that brief interventions in primary care and by clinicians in other settings are effective in reducing smoking.^8,9 In common with multiple organisations internationally, the Royal Australian College of General Practitioners in its guidelines on smoking cessation recommends the ‘5As’ approach, incorporating:^10,11

• 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
• Arranging follow up, to support sustained efforts to quit and remain abstinent. 

It is now known that in Australia smoking will kill most people who continue to smoke long term.¹ It is also known that quitting smoking at any age benefits health compared with continuing to smoke, with those people who cease before the age of 45 years avoiding almost all of the excess risks of premature death.¹ This means that if you support a few smokers to quit you have probably saved a life – something that we all aspire to. What could be more important, challenging and exciting?    CT

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