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Foreword
Acknowledgments
Chapter 1: Trends in the prevalence of smoking
1.1 A brief history of tobacco smoking in Australia
1.2 Overview of major Australian data sets
1.3 Prevalence of smoking—adults
1.4 Prevalence of smoking—young adults
1.5 Prevalence of smoking—middle-aged and older adults
1.6 Prevalence of smoking—teenagers
1.7 Trends in the prevalence of smoking by socio-economic status
1.8 Trends in prevalence of smoking by country of birth
1.9 Prevalence of tobacco use among Aboriginal and Torres Strait Islander peoples
1.10 Prevalence of smoking in other high-risk sub-groups of the population
1.11 Prevalence of smoking among health professionals
1.12 Prevalence of use of different types of tobacco product
1.13 Smoking by Australian states and territories
Chapter 2: Trends in tobacco consumption
2.0 Introduction
2.1 Production and trade data as a basis for estimating tobacco consumption
2.2 Dutiable tobacco products as an estimate of tobacco consumption
2.3 Self-reported measures of tobacco consumption
2.4 Expenditure on tobacco products
2.5 Industry sales figures as estimates for consumption
2.6 Comparisons of quality and results using various estimates of tobacco consumption in Australia
2.7 Factors driving changes in tobacco consumption
2.8 Per capita consumption in Australia compared with other countries
Chapter 3: The health effects of active smoking
3.0 Tobacco—a leading preventable cause of death and disease
3.1 Smoking and cardiovascular disease
3.2 Respiratory diseases (excluding lung cancer)
3.3 Smoking and cancer
3.4 Lung cancer
3.5 Other cancers
3.5.1 Oral, nasal and sinus cancers
3.5.2 Throat cancer and voice box cancer (cancers of the pharynx and larynx)
3.5.3 Stomach (gastric) and oesophageal cancers
3.5.4 Kidney, bladder and ureter cancers
3.5.5 Cervical cancer
3.5.6 Acute myeloid leukaemia
3.5.7 Liver cancer
3.5.8 Bowel (colorectal) cancer
3.5.9 Breast cancer
3.5.10 Pancreatic cancer
3.5.11 Ovarian cancer
3.5.12 Other cancers
3.6 Reproductive health
3.7 Pregnancy and smoking
3.8 Child health and maternal smoking before and after birth
3.9 Increased susceptibility to infection in smokers
3.10 Eye diseases
3.11 Dental diseases
3.12 Gastro-intestinal diseases
3.13 Musculoskeletal conditions
3.14 Skin
3.15 The impact of smoking on treatment of disease
3.15.1 The effects of smoking on surgery
3.15.2 Drug interactions
3.15.3 Treatment of cardiovascular diseases
3.15.4 Cancer treatment
3.15.5 Treatment of respiratory diseases
3.15.6 Treatment of other conditions
3.16 Smoking and diabetes
3.17 Inflammatory conditions and autoimmune disease
3.18 Other conditions with possible links to smoking
3.19 Smoking and accidents
3.21 Health effects for young people who smoke
3.22 Poorer quality of life and loss of function
3.23 Smoking, dementia and cognition
3.24 Genetic influences on tobacco-caused disease
3.25 Smoking compared with or in combination with other pollutants
3.26 Health effects of brands of tobacco which claim or imply delivery of lower levels of tar, nicotine and carbon monoxide
3.27 Health effects of smoking tobacco in other forms
3.28 Health 'benefits' of smoking?
3.29 Smoking and body weight
3.30 Burden of death and disease attributable to tobacco use in Australia
3.31 Morbidity and mortality due to tobacco-caused disease and socio-economic disadvantage
3.32 Health effects of smoking other substances
3.33 Health effects of chewing tobacco, and of other smokeless tobacco products
3.34 Public perceptions of tobacco as a drug, and knowledge and beliefs about the health consequences of smoking
3.35 Health and other benefits of quitting
3.36 Health effects of occasional (“social”) smoking and cutting down
3.37 Chemoprevention of tobacco-related disease
3.38 Quantifying the role of tobacco control in averting disease and early death
Chapter 4: The health effects of secondhand smoke
4.0 Background
4.1 What is secondhand smoke?
4.2 What is in secondhand smoke?
4.3 Thirdhand smoke
4.4 Measuring exposure to secondhand smoke
4.5 Prevalence of exposure to SHS in the home
4.6 Mechanisms of disease
4.7 Estimates of morbidity and mortality attributable to secondhand smoke
4.8 Cardiovascular disease and secondhand smoke
4.9 Lung cancer and secondhand smoke
4.10 Cancers of other sites
4.11 Effects of secondhand smoke on the respiratory system in adults
4.12 Secondhand smoke and increased risk of infectious disease
4.13 Secondhand smoke and type 2 diabetes mellitus
4.14 Secondhand smoke and mental health
4.15 Oral health
4.16 Secondhand smoke and pregnancy
4.17 Health effects of secondhand smoke for infants and children
4.18 Other health effects
4.19 Public attitudes to secondhand smoke
4.20 Health effects of secondhand smoke on pets
Chapter 5: Influences on the uptake and prevention of smoking
5.0 Stages in the uptake of smoking
5.1 Factors influencing uptake by young people overview
5.2 Prevention
5.3 Early biological factors
5.4 Adolescence and brain maturation
5.5 Temperament, mental health problems and self-concept
5.6 Intentions, attitudes and beliefs
5.7 Family and the home environment
5.8 The influence of peers
5.9 The educational environment
5.10 Culture and socio-economic aspects of uptake
5.11 Accessibility of tobacco products to young people
5.12 The impact of tobacco affordability and pricing on uptake, and policy to reduce affordability
5.13 Products and packaging that promote smoking uptake, and policies to reduce appeal
5.14 Smokefree policies
5.15 Tobacco advertising and promotion targeted at young people
5.16 Smoking in movies, TV and other popular culture media
5.17 Media campaigns and young people
5.18 Harnessing predictors of uptake to prevent smoking
5.19 The profound effects of the denormalisation of smoking
5.20 Factors influencing uptake of smoking later in life
5.21 Other drug use
Chapter 6: Addiction
6.0 Introduction
6.1 Defining nicotine as a drug of addiction
6.2 Pharmacokinetics
6.3 Mechanism of action
6.4 Pharmacological effects
6.5 Mood effects
6.6 Cognitive effects
6.7 Clinical populations
6.8 Interactions between tobacco smoke and medications
6.9 Predictors of nicotine dependence
6.10 Acute effects of nicotine on the body
6.11 Tolerance, dependence and withdrawal
6.12 Measures of tobacco dependence
6.13 Addiction and the adolescent smoker
6.14 Smokers’ attitudes to and beliefs about addiction
Chapter 7: Smoking cessation
7.0 Introduction
7.1 Health and other benefits of quitting
7.2 Quitting activity
7.3 Theories about smoking and quitting
7.4 What finally prompts smokers to attempt to quit?
7.5 What we know about how smokers are persuaded to attempt to quit
7.6 How smokers go about quitting
7.7 Environmental and biopsychosocial factors that influence quitting
7.8 How can relapse be prevented?
7.9 Increasing smoking cessation at the population level
7.10 Role of health professionals and social services
7.11 Smoking cessation and pregnancy
7.12 Cessation interventions for people with serious health conditions
7.13 Cessation assistance: printed self-help materials
7.14 Cessation assistance: telephone- and internet-based interventions
7.15 Individual and group-based cessation assistance
7.16 Pharmacotherapies for smoking cessation
7.17 Incentives and rewards for quitting
7.18 Alternative therapies and emerging treatments
7.19 Interventions tailored for age and/or gender
7.20 National strategies to support and increase cessation
7.21 Lung cancer screening and biomedical risk assessments
Chapter 8: Tobacco use among Aboriginal and Torres Strait Islander peoples
8.0 Introductory note
8.1 Aboriginal and Torres Strait Islander peoples: social disadvantage, health and smoking—an overview
8.2 History of tobacco use among Aboriginal and Torres Strait Islander peoples
8.3 Prevalence of tobacco use among Aboriginal and Torres Strait Islander peoples
8.4 Smoking among Aboriginal and Torres Strait Islander children and teenagers
8.5 Types of tobacco used by and levels of consumption among Aboriginal and Torres Strait Islander peoples
8.6 Smoking cessation and Aboriginal and Torres Strait Islander peoples
8.7 Morbidity and mortality caused by smoking among Aboriginal and Torres Strait Islander peoples
8.8 Economic issues relating to tobacco use among Aboriginal and Torres Straits Islander peoples
8.9 Attitudes to and beliefs about smoking among Aboriginal and Torres Strait Islander peoples
8.10 Tobacco action initiatives targeting Aboriginal and Torres Straits Islander peoples
8.11 The relationship between tobacco and other drug use in Aboriginal and Torres Strait Islander communities
8.12 The tobacco industry and Indigenous communities
8.13 Policies for advancing tobacco control programs among Aboriginal and Torres Strait Islander peoples
8.14 The effectiveness of population-level tobacco control strategies
8.15 The role of health workers and community organisations
Chapter 9: Smoking and social disadvantage
9.0 Introduction
9.1 Smoking prevalence and exposure to secondhand smoke among priority populations in Australia
9.2 Trends over time in smoking among priority populations in Australia
9.3 Contribution of smoking to health inequality
9.4 The relationship between tobacco smoking and financial stress
9.5 Smoking and intergenerational poverty
9.6 Tailored and targeted interventions for low socioeconomic groups
9.7 Explanations of socio-economic disparities in smoking
9.8 Are current strategies to discourage smoking in Australia inequitable?
9.9 Are there inequalities in access to and use of treatment for dependence on tobacco-delivered nicotine?
InDepth 9A Addressing smoking in highly disadvantaged and other priority groups
9A.1 People living in regional and remote areas of Australia
9A.2 Culturally and linguistically diverse groups
9A.3 People with substance use and mental disorders
9A.4 People experiencing homelessness
9A.5 People experiencing incarceration
9A.6 Lesbian, gay, bisexual, trans, queer and intersex (LGBTQI+) people
9A.7 Military personnel and veterans
9A.8 Single parents
Chapter 10: The tobacco industry in Australian society
10.0 Introduction
10.1 The tobacco growing industry
10.2 The global tobacco manufacturing industry
10.3 Tobacco companies operating in Australia
10.4 Market share and brand share in Australia
10.5 Products available on the Australian tobacco market
10.6 Trends in products and packaging
10.7 Brand portfolio strategies in the Australian tobacco market
10.8 Characteristics of the Australian retail tobacco market
10.9 Retailer experiences of and attitudes towards selling tobacco
10.10 The tobacco industry exposed: tobacco industry document repositories
10.11 Corporate responsibility and the birth of good corporate citizenship
10.12 The tobacco industry's revised stance on health issues
10.13 Industry efforts to discourage smoking
10.14 Ethical issues related to tobacco farming and production
10.15 The environmental impact of tobacco production
10.16 The environmental impact of tobacco use
10.17 Public attitudes to the tobacco industry
10.18 The investment of public funds in tobacco - the case for divestment
10.19 The future of the tobacco industry
In Depth 10A Strategies for influence
10A.1 Strategies for influence - Overview
10A.2 The arguments
10A.3 Mechanisms of influence—Industry-funded research
10A.4 Mechanisms of influence—undermining public health organisations
10A.5 Mechanisms of influence—mobilising support from the industry and those with shared aims
10A.6 Mechanisms of influence—media relations
10A.7 Mechanisms of influence—political lobbying
10A.8 Mechanisms of influence—participation in regulatory review processes
10A.9 Mechanisms of influence—litigation
Chapter 11: Tobacco advertising and promotion
11.0 Background
11.1 The merits of banning tobacco advertising
11.2 Tobacco industry expenditure on advertising
11.3 Commonwealth (national) legislation
11.4 State and territory legislation
11.5 Tobacco advertising legislation violations
11.6 Marketing of tobacco in the age of advertising bans
11.7 Promotional events
11.8 Trade promotions
11.9 Retail promotion and access
11.10 Smoking in movies as promotion
11.11 Internet promotion
InDepth 11A: Packaging as promotion: Evidence for and effects of plain packaging
11A.0 Introduction
11A.1 Plain packaging as a solution to the misleading and promotional power of packaging
11A.2 Australian announcement of plain packaging legislation
11A.3 Analysis of major industry arguments against plain packaging
11A.4 Milestones in adoption of legislation
11A.5 Major milestones in legal challenges to the legislation
11A.6 International flow-on effects
11A.7 Initial industry responses to attempt to mitigate the impact of legislation
11A.8 Experimental research on the effects of plain packaging
11A.9 Real-world research on the effects of plain packaging
InDepth 11B: Licensing of tobacco sellers
Attachment 11.1 TAP Act report to parliament
Chapter 12: Tobacco Products
12.0 Introduction
12.1 Tobacco in cigarettes
12.2 Other types of tobacco products
12.3 Chemicals and contaminants in tobacco products
12.4 Emissions from tobacco products
12.5 Measuring emissions and exposure to tobacco products
12.6 Additives and flavourings in tobacco products
12.6.1 Why are chemicals added to tobacco products?
12.6.2 Additives that increase the addictiveness of tobacco products
12.6.3 Additives that increase the attractiveness of tobacco products
12.6.4 Additives that modify the processing shelf-life and burn rates of tobacco products
12.6.5 Toxicity of tobacco product additives
12.6.6 Priority additives for reporting in Europe
12.6.7 Additives in Australian cigarettes
12.6.8 Perceptions of additives among the community
12.6.9 Consumer perceptions of flavoured tobacco products
12.6.10 Flavoured tobacco products used by specific groups of people
12.6.11 Effects of flavoured tobacco products on smoking initiation and cessation
12.6.12 Regulation of flavourings and flavoured tobacco products
12.6.13 Regulation of other additives
12.7 Menthol
12.8 Construction of cigarettes and cigarette filters
12.9 Labelling of tobacco products in Australia
InDepth12A: Health warnings
12A.0 Introduction and rationale for health warnings
12A.1 Graphic health warnings, on-product messages and health promotion inserts for tobacco sold in Australia
12A.2 History of health warnings in Australia
12A.3 Evidence about the effects of health warnings
12A.4 What makes an effective health warning?
12A.5 The impact of graphic health warnings in Australia
12A.6 Evidence for the effects of health promotion inserts
12A.7 Evidence for the effects of on-product dissuasive messages
12A.8 Health warnings used in other countries
12A.9 Public support for health warnings
InDepth 12B: Regulation to disclose or reduce harm from tobacco products
InDepth 12C: Reducing the nicotine content of cigarettes
InDepth 12D: Reduced fire risk (RFR) cigarettes
Chapter 13: The pricing and taxation of tobacco products in Australia
13.0 Introduction
13.1 Why increasing tobacco prices matters
13.2 The role of taxes in influencing tobacco prices
13.3 How much do tobacco products cost in Australia?
13.4 Factors that influence the price of tobacco products in Australia
13.5 How affordable are cigarettes in Australia?
13.6 What tobacco taxes apply in Australia?
13.7 Revenue from tobacco taxes in Australia
13.8 The impact of price increases on tobacco use in Australia
13.9 How do tobacco prices, affordability, taxes, and tax revenue in Australia compare to overseas?
13.10 Arguments against tax increases
13.11 The impact of tobacco tax increases on socioeconomically disadvantaged populations
13.12 Public opinion among Australians about tobacco taxes
13.13 Best practice recommendations and future directions for tobacco price and tax policy
InDepth 13A Avoidance and evasion of taxes on tobacco products
13A.0 Introduction
13A.1 Why is it important to address illicit tobacco trade?
13A.2 What terms are used to describe illicit trade in tobacco?
13A.3 Industry estimates of the extent of illicit trade in tobacco
13A.4 How can the extent of avoidance and evasion be quantified?
13A.5 Estimates of illicit cigarette trade in Australia
13A.6 What is known about drivers of illicit trade in tobacco internationally?
13A.7 What do international authorities recommend to address the illicit trade in tobacco?
13A.8 What has been done in Australia to reduce avoidance and evasion of tobacco taxes?
13A.9 Measures to further strengthen the current regulatory settings to address illicit tobacco trade in Australia
Chapter 14: Social marketing and public education campaigns
14.0 Introduction
14.1 Mass media public education campaigns: an overview
14.2 The role of mass media campaigns within a comprehensive smoking control program
14.3 Public education campaigns to discourage smoking: the Australian experience
14.4 Examining the effectiveness of public education campaigns
14.5 Targeting of public education campaigns and different types of media channels
14.6 News media coverage
Appendix 1 National, State and Territory Contacts
Chapter 15: Smokefree environments
15.0 Introduction
15.1 Why implement smokefree environments?
15.2 Public opinion about smokefree environments
15.3 Opposition to and weakening of smokefree environment
15.4 Smoking bans in key public areas and environments
15.5 Smoking bans in outdoor areas
15.6 Smoking bans in the home and car
15.7 Legislation to ban smoking in public spaces
Summary of smokefree legislation across Australian states and territories
15.8 Immediate impact of smokefree legislation in improving air quality
15.9 Effectiveness of smokefree legislation in reducing exposure to tobacco toxins, improving health, and changing smoking behaviours
Chapter 16: Tobacco litigation in Australia
16.0 Introduction
16.1 Personal injury claims against the tobacco industry
16.2 Litigation brought by Australian consumer and regulatory groups against the tobacco industry
16.3 Litigation by individuals
16.4 Criminal cases against the tobacco industry
16.5 Legal cases initiated by tobacco industry
Appendix 16.1 McCabe
Appendix 16.2 Australian cases
Chapter 17: The economics of tobacco control
17.0 Introduction
17.1 Economic terminology and methods
17.2 The costs and benefits of smoking to the Australian economy
17.3 The economic rationale for intervention in the tobacco market
17.4 Economic evaluations of tobacco control interventions
17.5 Impact of tobacco control strategies on the Australian economy
17.6 Optimal investment in tobacco control
Chapter 18: E-cigarettes and other alternative nicotine products
18.0 Introduction
18.1 E-cigarette products and the e-cigarette market
18.2 Advertising and promotion of e-cigarettes
18.3 Prevalence of e-cigarette use
18.4 Safety risks and abuse potential of e-cigarettes
18.5 Chemicals in e-liquids and e-cigarette aerosols
18.6 The health effects of e-cigarette use
18.6.1 Health effects of e-cigarette use during pregnancy
18.6.2 Health effects of e-cigarette use during adolescence
18.6.3 E-cigarette use and cardiovascular disease
18.6.4 E-cigarette use and possible cancer risk
18.6.5 E-cigarette use and the risk of non-infectious respiratory diseases
18.6.6 E-cigarette use and the risk of infectious diseases
18.6.7 E-cigarette use and oral health
18.6.8 Other health risks
18.6.9 Exposure to secondhand e-cigarette emissions
18.6.10 E-cigarette use and mental health
18.7 Effects of e-cigarette use on smoking
18.8 Population-level benefits and harms of increasing e-cigarette use
18.9 Influences on the uptake of e-cigarettes
18.10 Policies and programs to reduce e-cigarette use among young people and non-smokers
18.11 Cessation interventions to help people quit vaping
18.12 Public perceptions of the risks and benefits of e-cigarettes
18.13 Regulation of vapes in Australia
18.14 International regulatory overview
18.15 Position of Australian and international public health groups on e-cigarettes, health, and options for regulation
InDepth 18A: Smokeless tobacco
18A.1 Forms of smokeless tobacco (now located in 12.2.9)
18A.2 Prevalence of use of smokeless tobacco in Australia
18A.3 Health effects of various forms of smokeless tobacco
18A.4 Snus as a potential harm reduction strategy
18A.5 Regulating sale and promotion of smokeless tobacco
InDepth 18B: Heated tobacco products
18B.0 Introduction
18B.1 Types of heated tobacco products
18B.2 The heated tobacco product market
18B.3 Advertising and promotion of heated tobacco products
18B.4 Awareness, perceptions, and use of heated tobacco products
18B.5 Exposure to chemicals from heated tobacco products
18B.6 Health effects of heated tobacco products
18B.7 Effects of heated tobacco product use on smoking
18B.8 Public health and regulatory considerations
18B.9 Legal status in Australia
18B.10 International regulatory overview
18B.11 Key Australian and international position statements on heated tobacco products
InDepth 18C: Nicotine pouches and other non-therapeutic oral nicotine products
18C.1 Oral nicotine products and the oral nicotine market
18C.2 Advertising and promotion of oral nicotine products
18C.3 Awareness, perceptions and use of oral nicotine products
18C.4 Chemicals in oral nicotine products
18C.5 Health effects of oral nicotine products
18C.6 Public health and regulatory considerations
18C.7 Legal status of oral nicotine products in Australia
18C.8 International regulatory overview
Chapter 19: The WHO Framework Convention on Tobacco Control
19.0 The global response to the global tobacco epidemic
19.1 Integration of the WHO FCTC into broader global agendas
19.2 WHO FCTC governance framework
19.3 WHO FCTC guiding principles and general obligations
19.4 Obligations relating to demand reduction for tobacco products
19.5 Obligations relating to supply-reduction for tobacco products
19.6 Other substantive obligations
19.7 Obligations regarding international cooperation and exchange of information and resources
19.8 Implementation, compliance and enforcement of the WHO FCTC
19.9 Impact of the WHO FCTC and its influence on other bodies of law
19.10 Implications of the WHO FCTC for Australia
19.11 WHO FCTC in an Australian context: Case study example of Australia’s tobacco plain packaging measures
19.12 WHO FCTC in an Australian context: Case study example of guidance on interacting with the tobacco industry
Appendix 1 Useful weblinks to tobacco resources
A1.1 International data repositories
A1.2 Links to tobacco use data from surveys—national and state
A1.3 International tobacco control strategies
A1.4 Australian tobacco control strategies and documentation
A1.5 Major reviews on smoking and health
A1.6 History of tobacco in Australia
A1.7 Current Australian legislation
A1.8 Smoking cessation
A1.9 Smoking and Aboriginal and Torres Strait Islander peoples
A1.10 Economic costs of tobacco
A1.11 Tobacco industry document repositories
A1.12 Some key peer-review journals
A1.13 Current international legislation
A1.14 Policy implementation resources
A1.15 Understanding the tobacco industry
A1.16 Public perceptions of tobacco as a drug, and public opinion regarding tobacco control policies
Appendix 2 Forward-looking (“endgame”) measures in tobacco control
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The profound effects of the denormalisation of smoking
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Intro
Chapter 2