1.3.1 Latest estimates of smoking prevalence in Australia
The most recent available data on prevalence of smoking in Australia can be found in the reports of the 2022–23 National Drug Strategy Household Survey published by the Australian Institute of Health and Welfare1 and of the 2022 National Health Survey, published by the Australian Bureau of Statistics.2
National Drug Strategy Household Survey
Table 1.3.1 shows the prevalence of daily, regular, and current smoking among Australians aged 14+ and 18+. Fewer than one in ten Australians reported daily smoking in 2022–2023.1,3
In shorthand speech, the ‘prevalence of smoking among adults in Australia’ could be cited simply as 11.1% (the rate of current smoking for adults 18 years and older).
National Health Survey
According to the Australian Bureau of Statistics’ National Health Survey, the prevalence of daily smoking for Australians aged 18 and over in 2022 was 10.6%, and 10.2% among people aged 15 years and over. Current smoking prevalence was 12.2% for those aged 18+ and 11.7% for those aged 15+.2
1.3.2 Historical trends in smoking prevalence in Australia
Measurements of the prevalence of smoking in Australia first became available in 1945. Limited survey data4 are available for the years between then and 1974, when the Anti-Cancer Council of Victoria (now Cancer Council Victoria) conducted its first national survey.5,6 These early data show that in around the middle of the last century, a clear majority of males aged 16 and over smoked, compared to about one-quarter of females (Table 1.3.2). 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. 7-10 Women have always had a lower prevalence of smoking than men, but smoking among women continued to increase in the 1970s.
Table 1.3.3 shows the proportion of smokers in the population aged 18 and over from 1980 to 1998. Taking into account the ageing of the population and other demographic trends over that period by standardising this data to the 2001 population structure, 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 relatively by 15%. The differential in smoking rates between the sexes also continued to close (while remaining statistically significant across the years to 1998), largely due to greater 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, where the prevalence of smoking levelled at about 27%.
After this relatively static period in the 1990s, the decline resumed for both genders after 2001. Since 2001, there has been a statistically significant decline in the prevalence of smoking for men and women (controlling for age) and the total population (controlling for age and gender) —see Table 1.3.4.
Hill and colleagues have suggested that the pattern of decline in smoking prevalence correlates with the level of tobacco control activities occurring at the time.11,12 The drop in male smoking rates seen in the early 1980s coincided with a period of new, well-funded media-led Quit campaigns11 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 and Action on Smoking and Health, and the widely publicised activities of the fringe groups MOP UP and BUGA UP.i Conversely, the steady prevalence rates in both sexes seen during the 1990s correspond 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.11
The subsequent downturn in smoking prevalence seen by the end of the 1990s—see Figure 1.3.1—may be attributable to the combined effects of increased tobacco taxes,13 additional smokefree legislation, and the National Tobacco Campaign, a mass-media led program aimed at encouraging cessation, which was launched in June 199714 and ran over several subsequent years.15,16 (See also Chapter 10.) Throughout the 2010s, further declines in smoking prevalence occurred in the wake of large tobacco excise increases, plain packaging, and increasingly comprehensive smoking bans (see Figure A1.6 and Section 15.7).
The findings of the early studies from 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) reported smoking: 43% of men and 29% of women.17
A calibration study conducted by the Anti-Cancer Council of Victoria in 1998 found that ‘regular’ smoking (i.e., daily or weekly) in the Australian Institute of Welfare’s National Drug Strategy Household Survey gave approximately the same proportion as a person defining themselves as a smoker in the ACCV surveys, hence the use of these two measures provides the most consistent picture of long-term trends in smoking in Australia.18
Data from the ABS show that in 2001, the proportion of adults who smoked daily was 22.3%.19 In 2022, the daily smoking rate among Australian adults had more than halved and was 10.6%—see Figure 1.3.2.2
Another long-running source of information about the prevalence of smoking is the Single Source Survey established in 1974 by the Roy Morgan Research Company. Door-to-door interviews conducted each week throughout Australia generate data from over 50,000 survey respondents each year.
Cancer Council Victoria analysis of monthly data from this survey from the largest five-capital cities over the 15 years to August 2017 shows a continuing decline in smoking since mid-2006—see Figure 1.3.3.
Smoking remains a leading cause of death and disease in Australia; in 2018, tobacco use was the cause of 20,482 deaths (13%, or more than one in every eight).18 Since about one in six men and about one in eight women still smoke,19 and given that two–thirds of these smokers can be expected to die because of their tobacco use if they do not quit,20 the sequelae of tobacco-caused death and disease will remain for decades to come. Mortality caused by tobacco use is discussed in Chapter 3.
1.3.3 International comparisons of adult smoking prevalence
In 2019, an estimated 19.6% of the global population smoked—approximately 940 million males and 193 million females ages 15 or older worldwide. In general, the prevalence of smoking is declining across all regions/continents, though, prevalence is increasing in some countries, mostly in Africa. Despite declines in smoking prevalence, the majority of smoking-related deaths occur in countries with high and very high development due to decades-long delay between changes in smoking prevalence and changes in smoking-related mortality rates.23 As global patterns in tobacco use change, the burden of death can be expected to shift dramatically from the developed world to less wealthy countries.24 This is at least in part due to a lack of adequate tobacco controls.25
A paradigm illustrating the typical progression of tobacco use worldwide, first proposed by Lopez and colleagues26 and later adapted by the WHO,27 is reproduced in Figure 1.3.4. Many (but not all) countries’ experiences of patterns of tobacco use fit this model.
Stage I 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 I 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.27 The importance of tobacco farming in some countries in the region (e.g. 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; concerns about the health consequences of tobacco use are not high on the national agenda.28
In stage II of the paradigm, male prevalence of smoking increases to more than 50% in men, and women’s smoking rates also begin increasing. Uptake of smoking occurs at an earlier age, and, although there is 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 Southeast Asian, Latin American and North African regions, and to a lesser extent, China (the case of China is discussed further below).27
Stage III 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, and smoking becomes less accepted among the more educated groups of society. Smoking becomes less socially acceptable 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.27
Evolution into stage IV 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 UK, the US, Canada, New Zealand and Australia are at various points on the continuum in the fourth stage of the tobacco epidemic.27 However, comprehensive and continually monitored public health strategies remain critical to maintain and reinforce declines in smoking prevalence.27
As noted above, there are some countries for which the paradigm devised by Lopez and colleagues in Figure 1.3.4 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. Nevertheless the WHO model described above does provide 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 II of the model, the Singaporean government initiated a series of tobacco control measures which 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.26
Figure 1.3.5 and Figure 1.3.6 show prevalence data collected by the Organisation for Economic Co-operation and Development (OECD) of its member countries.29 The Tobacco Atlas published by the American Cancer Society and World Lung Foundation, and the Global Health Observatory published by the World Health Organization, have both compiled data on the prevalence of smoking in almost all other countries worldwide—see here and here.30, 31 The figures below are provided in order to give a general global overview. It is important to note that data sets between countries are not directly comparable, due to differences in sampling (most crucially the year of the survey). Further, studies which only take into account the smoking of manufactured cigarettes will underestimate tobacco use in countries where tobacco is widely used in other forms, such as in pipes, hand-rolled leaves or as chewing tobacco. This is a key consideration in countries where alternative methods of tobacco use are prevalent, such as in Sweden32 and throughout much of Southern and Southeast Asia.33, 34 The interested reader is referred in the first instance to the primary sources, which explain the parameters of each study.
The global impact of death and disease caused by tobacco smoking is discussed in Chapter 3, Section 3.36.
Figure 1.3.7 shows the prevalence of current smoking (daily, weekly, or less than weekly) from each of the major national surveys in Australia, the US, the UK, England, Canada and New Zealand since about 2010. As indicated in the notes below Figure 1.3.7, precise differences in rates of change in smoking prevalence in different countries cannot be reliably quantified due to methodological differences between surveys in different countries and between surveys in the same country. These differences include the methods by which data are collected, the inclusion or exclusion of different forms of tobacco products (e.g. some do, and some do not include cigar and pipe smoking), and the phrasing of questions. There have also been some changes in methodology in the same surveys within the same country over time, and data collection for many of the surveys was impacted by COVID-19 in 2020–21. However, each of these surveys do suggest a substantial decline in current smoking in all of these English-speaking countries over the past decade.
- Australia: the National Drug Strategy Household Survey1 is a triennial survey with about 24,000 participants per wave and a usual response rate of about 50%.
The ABS National Health Surveys2 2011-12, 2014-15,2017-18 and 2022.
- US: the National Health Interview Survey35 is conducted annually with about 35,000 households containing about 27,000 sample adults; due to the COVID-19 pandemic, sample response rates and respondent characteristics in 2020 differ from previous survey years.36
The Tobacco Use Supplement (TUS-CPS)37 is administered as part of the US Census Bureau's Current Population Survey approximately every 3-4 years. Approximately 54,000 households are interviewed for CPS each month, and individuals aged 18+ who have completed the CPS Core survey are eligible for participation in TUS-CPS.
- England: the Annual Population Survey38 – see notes below.
The Smoking Toolkit Study39 is a monthly household survey of representative samples of 1700–1800 adults (16+ years old) in England.
- UK: the Annual Population Survey38 is a very large survey (320,000) run continuously throughout the UK.40
- Great Britain: the Opinions & Lifestyle Survey41 moved from a monthly survey to a weekly survey in March 2020, and to a fortnightly survey in August 2021. It samples approximately 2,000 to 2,500 individuals per week.42
- New Zealand: the New Zealand Health Survey43 yields an annual sample size of approximately 13,000 adults; due to the COVID-19 pandemic, sample size and response rates were significantly lower in 2021-22and respondent characteristics in 2020 differ from previous survey years.44
The Health and Lifestyles Surveys45 have included between 1,600 and 3,000 adults (aged 15+).
- Canada: the Canadian Community Health Survey46 is an annual survey with about 65,000 respondents each year
Several surveys have been conducted to obtain detailed information about tobacco use in Canada: the Canadian Tobacco Use Monitoring Survey (CTUMS; up to 2011);47 the Canadian Tobacco, Alcohol and Drugs Survey (CTADS; 2013, 2015, and 2017);48 and the Canadian Tobacco and Nicotine Survey (CTNS; 2019 onwards). The 2022 CTNS had a sample of about 12,000 respondents.49
- For each of the surveys, certain populations are excluded from sampling, such as those in institutional settings (e.g., people experiencing incarceration or in psychiatric facilities), those experiencing homelessness, and people in the Armed forces.
Error bars represent 95% confidence intervals.
i 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 in the first instance to: Chapman S. Civil disobedience and tobacco control: the case of BUGA UP (Billboard Utilising Graffitists Against Unhealthy Promotions). Tobacco Control 1996;5:179–85. Available from
http://tobaccocontrol.bmj.com/cgi/reprint/5/3/179
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References
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