Policy paper

Tobacco and cardiovascular disease

1300 36 27 87 www.heartfoundation.org.au October 2007 PRO-087

Executive summary
Background Tobacco smoking is the largest preventable cause of disease and death in Australia;1 it has been estimated to result in 15,511 deaths nationally each year, with 3,656 of these deaths occurring among people aged 25 to 64 years.2 Approximately half of all people who smoke regularly will eventually be killed by their habit.3 Globally there have been more than 12 million premature deaths attributable to smoking since the first published Surgeon General s Report on smoking and health in 1964.4 In Australia, tobacco is also responsible for 7.8% of the total burden of disease, which encompasses mortality, disability, illness, impairment and injury.5 A substantial body of scientific evidence documents the many adverse health effects of tobacco use. There is now overwhelming medical and scientific evidence that the use of tobacco causes coronary heart disease3,6 8 and influences the rate of its progression.9 Smoking is a major cause of stroke10 14 and a range of cancers, including cancers of the lung, cervix, throat, bladder and tongue.15 With smoking comes an increased risk of other disabling conditions including female fertility and menstrual problems16 and male impotence.17 Research has also implicated tobacco use with a number of other diseases, including diabetes18,19 and macular degeneration, which can cause blindness.20 It is associated with increased risk of vascular injury, vascular dysfunction7,21 coronary artery spasm and cardiac arrhythmias.22 The number of cigarettes smoked per day has an impact upon risk. Heavier smokers are at increased risk of developing many diseases.13,18,23 26 Heavy tobacco use is also associated with an increased risk of post-operative complications,27 including post-operative cardiopulmonary complications, infections, impaired wound healing and post-operative intensive care admission.28 However, light smokers are still at risk; even smoking as few as one to four cigarettes per day can double or triple coronary risk.7,29 Stopping smoking has a direct impact on the risk of disease occurrence and progression. There is now clear evidence that stopping smoking decreases the risk of cardiovascular disease,30 death from coronary heart disease6,10,31,32 and experiencing a stroke.10,11 Smoking cessation makes a significant contribution in primary and secondary prevention and management of cardiovascular disease33 and is a critical component in the prevention and treatment of diabetes.34 The risk posed by tobacco use extends beyond actual users. Scientific evidence has now unequivocally established that non-smokers exposure to tobacco smoke causes death, disease and disability.35 Exposure to second-hand tobacco smoke has been shown to have deleterious effects on cardiovascular health,7,36 with a 25 to 30% increase in the risk of coronary heart disease.37 Encouragingly, there has been a continual decline in the prevalence of smoking in Australia since the early 1980s. However, this declining trend masks stark differences in prevalence among some population groups. Population groups with higher prevalence of smoking include people who are: socio-economically disadvantaged, Indigenous, from some cultural backgrounds, in custodial settings, and suffering mental illness.38 There is a strong social gradient evident in the prevalence of smoking, increasing as the level of socio-economic disadvantage increases.39

Effective approaches for tobacco control The broad aim of tobacco control is to reduce smoking and its health consequences by: reducing uptake of smoking reducing consumption of tobacco promoting cessation of smoking protecting non-smokers from second-hand smoke.40 Tobacco-control advocates have long recognised the need for a comprehensive approach.41 International reviews consistently demonstrate that the most effective approaches to tobacco control are multifaceted and include a range of measures that complement and reinforce each other.42 46
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From such evidence-based reviews, 10 core components of an effective approach to reducing the use of tobacco and its effects on health and society emerge. 1. Taxation and pricing of tobacco products 2. Mass-media advertising (including paid and unpaid). 3. Smoke-free policies and regulations. 4. Regulation of tobacco advertising and promotion, including the generic packaging of cigarettes and other tobacco products. 5. Regulation of product availability and sale of tobacco to minors. 6. Regulation of the product. 7. Education about the effects of smoking on health. 8. Support for cessation and prevention of relapse. 9. Health professional and healthcare system interventions. 10. Strategies to postpone or prevent the onset of smoking. The National Heart Foundation of Australia recognises the need for a range of measures to build on the success achieved to date in reducing the number of people who smoke. This is reflected in the tobacco-control programs undertaken directly by the Heart Foundation or in partnership with other organisations, and in the role the Heart Foundation plays in advocating for tobacco-control measures. There are several key strategy documents pertinent to tobacco control that the Heart Foundation supports, and has helped develop. These include the: National Tobacco Strategy (2004 2009) National Strategy for Heart, Stroke and Vascular Health in Australia (2004) Guidelines for preventing cardiovascular events in people with coronary heart disease (2004) Framework Convention on Tobacco Control (2003).

Tobacco: the challenge for Australia While Australia leads many countries in its progress in tobacco control, the prevalence of smoking and its impact on the health system and the community remains a major public health challenge. In particular there remains the need to: accelerate the rates of decline in the prevalence of smoking among adults and young people reduce disparities in the prevalence of smoking among Aboriginal and Torres Strait Islander peoples, pregnant women, people who experience disadvantage, prisoners, people with mental illness and some cultural and linguistic groups help smokers to quit and avoid relapse secure sustained funding for tobacco-control campaigns and strategies elevate the priority given by the health system to support smoking cessation reduce exposure to second-hand smoke.

Key tobacco strategies and issues to be advocated for and supported by the Heart Foundation The Heart Foundation seeks to pursue activities that are complementary to the framework provided by the National Tobacco Strategy (2004 2009), and recommended the following priority areas for action during 2007 2008.

National Tobacco Campaign The Heart Foundation calls for an information and education campaign (a National Tobacco Campaign). The campaign should be funded by an increase in federal tobacco excise and should include the following elements. 1. An expert Ministerial Tobacco Advisory Group, comprising leading tobacco-control experts, working directly with the Federal Minister for Health. The advisory group will consult with health non-government organisations and other organisations active in tobacco control to guide the implementation of the National Tobacco Campaign.

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2. Taxation and pricing to regularly increase the price of tobacco products, including changing the way roll-your-own tobacco is taxed to ensure that these products are taxed in the same way as manufactured cigarettes. 3. Support governments and local governments to implement smoke-free policies that minimise exposure to second-hand smoke in both indoor and outdoor areas, and encourage smoking cessation. 4. National leadership to encourage all state and territory jurisdictions to prevent the display of cigarette packs and remove all remaining forms of tobacco promotion at the point of sale. 5. Closer regulation of the tobacco industry to include full, mandatory disclosure of all ingredients in tobacco products. 6. New regulation to prevent the use of additives that make tobacco smoke more palatable and addictive, particularly to children. 7. A ban on the sale of cigarettes that do not comply with Standards Australia s standard for Reduced Ignition Propensity (RIP) cigarettes in order to reduce death and injury from cigarette-ignited fires, including bushfires. 8. Legislation that would require the generic packaging of cigarettes and other tobacco products. 9. Sustained funding of dedicated tobacco-control programs for Aboriginal and Torres Strait Islander peoples and other high-risk groups (e.g. those with mental illness), to include access to subsidised nicotine replacement therapy and support for a tobacco-control campaign through dedicated, federally funded smoking cessation programs. 10. Denying the tobacco industry access to any government subsidies or incentives, such as research and development grants. 11. Urging all political parties to adopt a policy to not accept donations from tobacco companies, either directly or through third parties. 12. Opposing any request to the Australian Government by tobacco companies to introduce new smokeless tobacco products to the Australian market that are purported by them to be safer or lower risk (Appendix 1).

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Contents
1 2 2.1 2.2 3 3.1 3.2 4 4.1 4.2 4.3 Introduction ................................................................................................................................... 6 The effects of tobacco on health ................................................................................................. 7 Overview................................................................................................................................. 7 Tobacco and cardiovascular disease ..................................................................................... 7 Impact of tobacco on society..................................................................................................... 12 The toll of death and disease caused by smoking ............................................................... 12 The costs of smoking............................................................................................................ 13 Trends in smoking prevalence .................................................................................................. 14 Prevalence of smoking among adults .................................................................................. 14 Prevalence of smoking among specific population groups .................................................. 14 Attempts and desire to quit smoking .................................................................................... 15

5 Effective approaches for tobacco control ................................................................................ 16 5.1 Taxation and pricing of tobacco products............................................................................. 16 5.2 Regulation of tobacco advertising and promotion ................................................................ 16 5.3 Regulation of product availability and sales of tobacco to minors ....................................... 17 5.4 Product regulation ................................................................................................................ 17 5.5 Mass media advertising (including paid and unpaid) ........................................................... 18 5.6 Education about the effects of smoking on health ............................................................... 18 5.7 Support for cessation and prevention of relapse.................................................................. 19 5.8 Health professional and healthcare system interventions.................................................... 19 5.9 Smoke-free policies and regulations .................................................................................... 20 5.10 Strategies to postpone or prevent onset of smoking............................................................ 20 6 7 7.1 7.3 Tobacco: the challenge for Australia ........................................................................................ 21 A Heart Foundation response to tobacco ................................................................................ 22 The potential impact of reductions in smoking on cardiovascular disease in Australia ....... 22 Key tobacco-control strategies advocated for and supported by the Heart Foundation ...... 25 29 31

Appendix.. References...

2007 2010 National Heart Foundation of Australia ABN 98 008 419 761 ISBN: 978-1-921226-67-0 This work is copyright. No part may be reproduced in any form or language without prior written permission from the National Heart Foundation of Australia (national office). Enquiries concerning permissions should be directed to copyright@heartfoundation.org.au. Disclaimer: This document has been produced by the National Heart Foundation of Australia for the information of health professionals. The statements and recommendations it contains are, unless labelled as expert opinion , based on independent review of the available evidence. Interpretation of this document by those without appropriate medical and/or clinical training is not recommended, other than at the request of, or in consultation with, a relevant health professional. While care has been taken in preparing the content of this material, the National Heart Foundation of Australia and its employees cannot accept any liability, including for any loss or damage, resulting from the reliance on the content, or for its accuracy, currency and completeness. This material may be found in third parties programs or materials (including but not limited to show bags or advertising kits). This does not imply an endorsement or recommendation by the National Heart Foundation of Australia for such third parties organisations, products or services, including these parties materials or information. Any use of National Heart Foundation of Australia material by another person or organisation is done so at the user s own risk. The entire contents of this material are subject to copyright protection.

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Introduction

Tobacco smoking is the largest preventable cause of disease and death in Australia,1 accounting for 15,511 deaths in 2003.2 Of these, 3,656 (24%) occurred in people aged 25 to 64, and 11,795 in people aged over 64.2 Smoking is a major risk factor for cardiovascular disease, as well as a range of cancers, stroke and other disabling conditions. Approximately half of all people who smoke regularly will eventually be killed by their smoking.3 The risk of tobacco use extends beyond actual smokers. There is clear evidence of the harm to adults and children from exposure to second-hand smoke in homes, workplaces and enclosed public places.8,47 In Australia, more than a third (37%) of children aged 0 to 14 years live in households with one or more regular smokers, while 10% of children aged 0 to 14 years live in households where there is at least one regular smoker who smokes indoors.1 In addition to causing morbidity and premature mortality, smoking significantly reduces quality of life48 and places a huge financial drain on the health sector, as well as the broader community.49 The annual social cost of tobacco use in Australia in 1998 99 was estimated to be approximately $21 billion.50 Throughout the world, leading governments and health agencies have instigated tobacco-control policies to prevent tobacco use by young people, reduce tobacco use by adults, and reduce the exposure of non-smokers to second-hand smoke. Evidence shows that a comprehensive approach to tobacco control is required to affect the prevalence of smoking and reduce the terrible consequences and costs of tobacco use to individuals, families, communities and the health system.

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2.1

The effects of tobacco on health

Overview

Every day in Australia, approximately 42 people die prematurely from tobacco smoking.2 In the most recent follow-up of the longitudinal British Doctors Study, smokers died, on average, 10 years younger than non-smokers.51 A 50-year-old smoker who gave up smoking halved his risk of dying; the risk for a smoker who quit at age 30 was almost that of a never-smoker.51 There is a substantial body of scientific evidence documenting many adverse health effects of tobacco use. Smoking is a major cause of cardiovascular disease, and many cancers including cancers of the lung, cervix, throat, bladder and tongue.15 Women who smoke can suffer reduced fertility and menstrual problems, and if they smoke during pregnancy there are increased risks of miscarriage, problems with the placenta, stillbirth, complications during labour and a baby with low birth weight.16 For males, tobacco use has been identified as an important risk factor for impotence.17 Research has also implicated tobacco use in a number of other diseases and disabling conditions, including diabetes18,19 and macular degeneration, which can cause blindness.20 Heavy tobacco use is associated with an increased risk of post-operative complications,27 including post-operative cardiopulmonary complications, infections, impaired wound healing and post-operative intensive care admission.28 Scientific evidence has now unequivocally established that non-smokers exposure to tobacco smoke causes death, disease and disability.35 The report of the US Surgeon General released in 200637 states that there is no risk-free level of exposure to second-hand smoke.37 Second-hand smoke can cause cardiovascular disease, lung cancer and respiratory tract irritation; an increased risk of bronchitis, pneumonia, onset of asthma in children, sudden infant death syndrome, otitis media; and increased frequency and severity of asthma symptoms.37 Second-hand smoke exposure may also increase complications both during and after surgery,28 and there is evidence of a link between maternal exposure to second-hand smoke and pre-term delivery and low birth weight.37

2.2

Tobacco and cardiovascular disease

Evidence for a relationship between smoking and coronary heart disease (has been accumulating since the 1940s.52 In 1954, a study conducted by the American Cancer Society, based on 5,000 deaths among 190,000 men followed for two years, concluded that regular smoking of cigarettes causes an increase in death rates from both coronary thrombosis and cancer of the lung.52 There is now overwhelming medical and scientific evidence that the use of tobacco causes cardiovascular disease.3,6 8 Yet despite the well-established and publicised effects of smoking on cardiovascular health, many smokers deny that they are at elevated risk from smoking, with some studies indicating that less than one-third of smokers perceive themselves to be at greater than average risk of heart attack.53,54 Smoking is a major factor in both the development and rate of progression of a cardiovascular disease event.9 Smoking status is associated with the occurrence of a subsequent cardiovascular disease, with an odds ratio for those who have never smoked being 0.44 compared to continuing smokers.33 In the year 2000 an estimated 1.62 million cardiovascular deaths worldwide were due to smoking.55 In Australia, 13% of deaths from cardiovascular disease are attributed to cigarette smoking.56 Encouragingly, the decline in the incidence of heart attack and stroke observed in Australia in recent years appears, in part, to be attributable to corresponding declines in the prevalence of smoking in the population.57 Both mainstream (directly inhaled) tobacco smoke and exposure to second-hand tobacco smoke have been shown to have deleterious effects on cardiovascular health.7,36 As cigarette smoke contains more than 4,000 chemicals, the process of determining the precise mechanisms by which smoking causes cardiovascular disease is complex.7 Over the past few decades, however, researchers have identified a number of causal relationships between smoking and cardiovascular disease, through both acute and chronic mechanisms.58 Mainstream tobacco smoke has patho-physiological effects on the heart,
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coagulation system, blood vessels and lipoprotein metabolism.7,59 Smoking promotes the build-up of coronary plaques and predisposes smokers to the rupture of plaques and coronary thrombosis.60 It also contributes to the development and acceleration of atherosclerosis.7,21,22 Tobacco smoking is associated with increased risk of vascular injury, vascular dysfunction,7,21 coronary artery spasm and cardiac arrhythmias.22 The physiological, haematological and metabolic changes associated with smoking result in an increased myocardial demand for oxygen and a reduced capacity for the delivery of oxygen.9,22 This increased oxidative stress is indicated as a potential mechanism for initiating cardiovascular dysfunction.59 2.2.1 Types of cardiovascular disease caused by smoking

Coronary heart disease (CHD) Overall, smokers have between a 1.613 and two-fold greater incidence of coronary heart disease (CHD) and 70% greater mortality from CHD than non-smokers.6 Specifically, smoking has been associated with a two- to six-fold increase in males in the risk for myocardial infarction,61,62 a major form of CHD. It has also been associated with a three-fold increase in the risk for incident angina.62 There is a clear dose relationship between CHD and the duration (years) of smoking, the number of cigarettes smoked,13 the degree of inhalation, and the age of initiation of smoking.7,16,63,64 Heavy smokers of more than 40 cigarettes per day experience a four-fold greater incidence of CHD, and a two- to three-fold greater death rate from CHD compared with non-smokers.6 Even smoking one to four cigarettes per day can double or triple coronary risk.7,29 While historically women have had lower rates of CHD than men, this has in part been attributed to past gender differences in the prevalence of smoking and the number of cigarettes smoked.6 Higher current patterns of smoking among women have implications for the future incidence of cardiovascular disease in females.7 As well as the effects of smoking on the cardiovascular system generally, women who smoke and use oral contraceptives have an elevated risk of CHD.6,16 The risk appears to be greatest among women over the age of 35 who are heavy smokers and use oral contraception.7,65 Smoking is also linked to earlier menopause66 which, in turn, is associated with increased risk of CHD.62 Stroke Smoking has been established as a risk factor for stroke in both men and women.10 14 Up to 25% of all strokes can be directly attributed to cigarette smoking. The relative risk of stroke among smokers, previously suggested as three-fold,11,23 is now thought to be even higher, with a recent study suggesting it to be as high as five-fold.24 There is a dose relationship between number of cigarettes smoked and the relative risk of stroke,23,24 and evidence has also implicated pipe and cigar smoking as elevating stroke risk.11 Earlier studies of female smokers who used higher-dose oral contraceptives found the risk of stroke greatly increased.6 A recent prospective study of women receiving hormone replacement therapy indicated that risk of stroke was higher in smokers. There is conflicting evidence pertaining to the risk of stroke among smokers on currently available lower-dose oral contraceptives.16 Peripheral arterial disease Cigarette smoking is the most significant risk factor for peripheral arterial disease, with a doseresponse relationship.25 As well as having adverse health effects in itself, peripheral arterial disease is also an independent predictor of cardiovascular death.67 Additionally, smoking can reduce the efficacy of some cardiovascular drug therapies.9 The incidence of peripheral arterial disease is relatively rare in people who have never smoked,6 with 90% of those with atherosclerotic peripheral vascular disease being smokers.6 There is a six- to 30-fold increased risk of peripheral arterial disease associated with smoking.68 Abdominal aortic aneurysm Rupture of an abdominal aortic aneurysm has a high case fatality, with 1% of deaths in the Western world attributed to this cause.26 Smoking has been identified as a strong risk factor for abdominal aortic aneurysm69 71 in both men and women,26 with a six- to seven-fold increased risk for current smokers.26 There is a clear dose relationship between duration of smoking (years) and elevated risk for abdominal aortic aneurysm.26 Smoking is an overlapping risk factor for abdominal aortic aneurysm and atherosclerosis.71 Further research is required to establish the pathogenesis of abdominal aortic
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aneurysm, and whether smoking exerts an effect independent of its links to the development of atherosclerosis.26 Second-hand smoke and cardiovascular disease The compounds in tobacco that are implicated in damaging the health of smokers are also present in second-hand smoke, and exposure has immediate adverse effects on the cardiovascular system.37 While the increased risk from second-hand smoke is smaller than the risk from active smoking, second-hand smoke is still a significant risk factor for cardiovascular disease among non-smokers.36,72 In addition to its link to the onset of cardiovascular disease, second-hand smoke can precipitate acute manifestations of cardiovascular disease and impact negatively on the outcome of patients suffering acute coronary syndromes.36 The most recent synthesised meta-analyses of evidence indicate a 25 to 30% increase in the risk of CHD from exposure to second-hand smoke.37 Individual studies report an elevated risk of CHD as high as 50 to 60% among non-smokers exposed to second-hand smoke.73 While research to date has tended to focus on the risks of living with someone who smokes, this study included exposure to other people s smoke in workplaces and recreational settings (e.g. pubs and clubs) as well as homes, and measured cotinine levels as the marker of exposure.73 There is increasing evidence that second-hand smoke is atherogenic and can increase the risk of stroke among non-smokers who are exposed to second-hand smoke.11 However, the most recent US Surgeon General s review of evidence is more cautious, indicating that the evidence is suggestive but not sufficient to infer a causal relationship between exposure to second-hand smoke and an increased risk of stroke.37 Second-hand smoke can also contribute to complications during and after surgery,28 including increased risk of respiratory complication during surgery in adults,74 respiratory events or complications during and after surgery in children,75,76 and differences in drug metabolism in children.77 In addition to the potential longer-term effects there is evidence that even very short-term exposure to second-hand smoke can adversely affect endothelial functions in healthy non-smokers, and be detrimental to the body s cardiovascular system.78,79 Although the increase in risk of cardiovascular disease associated with second-hand smoke is relatively modest at a population level, its impact in the form of excess CHD morbidity and mortality is still substantial.80 In the United States, for example, it has been estimated that 46,000 deaths each year are attributable to involuntary smoking.37 2.2.2 Smoking and other risk factors for cardiovascular disease

While cigarette smoking is a major risk factor for cardiovascular disease, it also acts multiplicatively with other risk factors to further increase the risk of CHD.6,22,81 Smoking is also an overlapping risk factor with low HDL cholesterol and blood pressure in the development of abdominal aortic aneurysm.26 There is emerging evidence that tobacco contributes to the development of depression82 and affects stress-managing neural pathways, which may reduce capacity to deal with the challenges of life.83 Diabetes is another major risk factor for cardiovascular disease,56 and diabetes and cardiovascular disease are increasingly recognised as overlapping syndromes with common causal factors.84 There is accumulating evidence to suggest that cigarette smoking is a risk factor for diabetes,18,19,85,86 with evidence of a dose-response relationship between the number of cigarettes smoked each day and the incidence of diabetes.18 The existence of diabetes can also magnify the effect of other risk factors for cardiovascular disease, including smoking.56 Given that people with diabetes are more likely to have a number of cardiovascular risk factors,56 smoking cessation is a critical component of the prevention and treatment of diabetes.34 Moreover, cessation of smoking is reported to reduce the risk of diabetes, with one study finding that the incidence of diabetes among former smokers is lower than that of continuing smokers within five to 10 years.18 Considering smoking in the context of other cardiovascular disease risk factors is also relevant because of increasing evidence of the need for multifactorial continuing care to reduce cardiovascular mortality. Both diabetes and smoking have been identified as predictors for adverse outcomes in hypertensive patients with coronary artery disease.87 Smoking is one of the most important modifiable risk factors, and cessation of smoking needs to be encouraged as part of the management and continuing care of patients with cardiovascular disease.88 90
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Smoking, inappropriate diet and physical inactivity (as expressed through unfavourable lipid profiles, high body mass index and raised blood pressure) are the most important risk factors for cardiovascular disease, and together explain at least 75% of new cases of cardiovascular disease.91 There is clear evidence of a rapid decrease in cardiovascular risk following cessation of smoking.30 Smoking cessation makes a significant contribution to primary and secondary prevention and management of cardiovascular disease.33 Further research is needed to find effective cessation strategies for patients with cardiovascular disease.92 To achieve significant reductions in the burden of CHD on society, exposure to second-hand smoke also needs to be addressed.93,94 2.2.3 Prevention of cardiovascular disease

Cessation of smoking significantly reduces the risk of death from CHD.6,10,31,32 Numerous studies concur that there is a rapid decline in the risk of CHD within one year of cessation.10,31,32,95,96 Thereafter, the risk more gradually declines to the levels of a never-smoker,10 but there are conflicting reports on how long this takes.31 A recent US Surgeon General s report4 concluded that the excess risk of CHD caused by smoking is reduced by about half after one year of smoking cessation and then declines gradually, and that 15 years after abstaining from smoking, the risk of CHD is similar to that in those who have never smoked. Other recent studies have found a more rapid reduction in risk, concurring that the risk of heart attack or major coronary events declines rapidly after quitting smoking, and returns to the level of risk for never-smokers within two to six years.32,95,96 A large population-based case-control study undertaken in Australia and New Zealand found that the risk of having a major coronary event begins to fall within 12 months of cessation, is substantial one to three years following cessation, and returns to that of a never-smoker within four to six years of quitting.32 However, more recent research has indicated that within three years of quitting, risk of a myocardial infarction (heart attack) reduced to 1.9 compared to never smoking, but a residual excess risk of 1.2 remained for 20 or more years after quitting.97 The reduction in risk after cessation of smoking appears to be similar for men and women.32 The risk of suffering a stroke begins to fall soon after the cessation of smoking,10,11 with most of the benefit of quitting occurring within two to five years.11,98 Similar reductions in risk of stroke have been observed for men and women.10 There is conflicting evidence on whether the benefits of smoking cessation for reduction in the risk of stroke are influenced by the number of cigarettes smoked per day.11 Data from the Nurses Health Study indicate that the patterns of reduction in risk of stroke are the same regardless of number of cigarettes smoked, the age of initiation of smoking, or the presence of other risk factors for stroke,98 but another study found a longer legacy of elevated risk among heavier smokers.99 There is a lower risk of peripheral arterial disease among ex-smokers compared with current smokers, and cessation improves the prognosis of patients with established peripheral arterial disease.4,9 Complications from peripheral arterial disease are reduced among patients who have quit smoking.9,10 Smoking cessation in these patients also increases exercise tolerance, reduces the risk of amputation after surgery, and increases overall survival.4 Unlike other forms of cardiovascular disease for which there is a more rapid reduction of risk following cessation, an excess risk for abdominal aortic aneurysm can remain even 20 years after the cessation of smoking.6,100 However, the risk of abdominal aortic aneurysm does decrease slowly after the cessation of smoking,10 with the reduction in risk mainly attributed to the reduced duration of smoking.26 2.2.4 Continuing care and management of cardiovascular disease

It is never too late for smokers to quit, even if they already have some form of cardiovascular disease.101 Smoking cessation is an accepted and major component of cardiac rehabilitation programs102 and is advocated in guidelines for preventing cardiovascular events in people with CHD.90 Cessation of smoking can reduce the recurrence of myocardial infarction and reduce the likelihood of morbidity and mortality from recurrent coronary events,4,33,103 as well as the development of other forms of cardiovascular disease.21 Cessation also improves the outcomes of coronary angioplasty and coronary artery bypass surgery.22,104 Interventions to encourage cessation of smoking among people with a high risk of cardiovascular disease (either related to smoking history or the presence of other
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cardiovascular risk factors) are warranted.105 It has even been argued that care of patients with, or at high risk of, cardiovascular disease has greater potential than primary prevention to reduce mortality from cardiovascular disease at the population level.88 Despite the demonstrated benefits of quitting smoking for preventing coronary events, many patients continue to smoke after being diagnosed with CHD,106 or after experiencing major coronary events such as myocardial infarction or bypass surgery.105 Data from an Australian hospital-based cardiac risk assessment program showed that 22% of patients discharged following a heart attack or other coronary event were still smoking.107 A recent review of the impact of smoking cessation and smoking interventions on patients with CHD found that patients who continue to smoke after a myocardial infarction have a higher relative risk of mortality, repeat infarction or clinical complications than those who quit.105 In a US study of coronary bypass surgery patients, continued smoking was the major predictor of graft failure and recurrent cardiovascular events.108 Smoking is considered particularly dangerous for patients with advanced coronary atherosclerosis.109 Continued smoking can also have an adverse impact on outcomes of treatment for peripheral arterial disease, and has been linked to post-surgical complications and less improvement in symptoms of peripheral arterial disease.6 Although there has been considerable progress in the treatment of cardiovascular disease and its symptoms, its case fatality remains high, prompting calls for even greater emphasis on reducing risk factors in treating patients with cardiovascular disease.89,108,110,111 There have also been calls for further research to determine effective tobacco-cessation strategies for patients with cardiovascular diseases.92 The benefits of stopping smoking accrue rapidly (within one year) for patients who have suffered heart failure, and it is argued that supporting efforts to quit smoking may achieve comparable reductions in mortality and be more cost effective than pharmaceutical treatments such as beta-blockers and ACE inhibitors.101 A recent Australian study modelled the significant reductions in acute myocardial infarction and hospitalisations for stroke and savings that would result, even in the short-term, from stopping smoking.112 Whereas drug treatments for heart failure need to be continued for the life of the patient, the cost of cessation of smoking is a one-off investment, and on a population scale, can represent major savings to the health system in terms of cardiovascular disease prevented.101,113 Additionally, smoking can reduce the efficacy of some cardiovascular drug therapies.9 It has been argued that health professionals need to encourage cessation of smoking as strongly as they do the use of pharmaceutical treatments to reduce cardiovascular risk.89,90,101 The occurrence of a major cardiac event is recognised as an opportunistic and potentially effective time to encourage cessation of smoking,21,108 presenting a teachable moment where patients may be more receptive to advice on cessation or intervention.22 Cessation programs using inpatient counselling and telephone follow-up have been shown to assist, with significant improvements in the rate of smoking cessations.114 Another recent study indicated that more intense interventions resulted in doubling the quit rates whereas interventions of low intensity did not appear effective,115 concluding that smoking cessation interventions are effective in promoting abstinence up to one year, provided they are of sufficient intensity and a minimum length of one month.115 Despite this finding, cessation of smoking is promoted inadequately. A US study found that 75% of patients admitted to hospital for myocardial infarction did not receive instruction in cessation of smoking.116 Other data similarly indicate poor rates of counselling112,117 on cessation or follow-up of smoking status for cardiovascular patients discharged from hospital.89 The provision of advice on cessation in general practice settings is also sub-optimal,118 with only 34% of GPs in a recent Australian study reporting that they provide advice on cessation in every routine consultation with smokers.119

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3.1

Impact of tobacco on society

The toll of death and disease caused by smoking

Since the first published Surgeon General s report on smoking and health in 1964,4 more than 12 million premature deaths globally have been attributed to smoking. In Australia, tobacco is responsible for 7.8% of the total burden of disease, which encompasses mortality, disability, illness, impairment and injury.5 Worldwide, tobacco smoking is a major identifiable factor contributing to the gap in life expectancy between those most in need, and those most advantaged. In Australia, it has been estimated that smoking is responsible for 15,511 deaths each year2 and over 142,000 admissions to hospital annually.120 Tobacco smoking is the leading preventable cause of death (see Figure 1) and accounts for 14 times more deaths per year than alcohol and nine times the number of deaths attributed to illicit drugs.2 Around 13% of deaths from cardiovascular disease in Australia (the leading cause of death) are attributable to tobacco smoking;56 in 1998, this represented over 6,600 deaths from cardiovascular disease.56 Figure 1: Number of people who died in 2003 due to smoking compared with other causes2
16000 15000 14000 13000 12000 11000 Number of Deaths 10000 9000 8000 7000 6000 5000 4000 3000 2000
1084 1705 655 435 1654 4568 9525 13491 13655 15511

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Source of data: Beggs S, Vos T, Barker B. The burden of disease and injury in Australia 2003. AIHW, 2007.

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3.2

The costs of smoking

Tobacco use imposes a significant financial drain on the community. For example, in 1998 99 health economists estimated that the non-voluntary and social costs of smoking were approximately $21 billion.50 These costs include healthcare expenditure, costs to smokers, their families and friends, costs to businesses, and the costs to public infrastructure. As a major cause of premature death and debilitating diseases and conditions, smoking greatly diminishes quality of life.48 It affects not only the person who has smoked, but also their family, friends and colleagues. Few Australians do not know one or more persons who have died or suffered as a result of a disease caused by smoking.

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4.1

Trends in smoking prevalence

Prevalence of smoking among adults

There has been a decline in the prevalence of smoking in Australia since the early 1980s, although this decline has not been continuous. Large gains were made in the early 1980s; however, in the mid 1990s the decline stalled before a significant drop was again achieved between 1997 and 2001.121 In the 2004 National Drug Survey, 17.4% of people aged 14 and over reported daily smoking, declining from 21.8% in 1998, and since 1985 there has been a decline of 40% in smoking rates.122 There are gender and age variations in the prevalence of tobacco use in Australia, although since the early 1980s the differential in smoking prevalence between men and women has decreased. Overall, the prevalence of smoking is higher among males than females, except in the 14 to 19 years age group, where females are more likely to smoke daily than their male teenage counterparts. Smoking prevalence was highest among males and females aged 20 to 29 years compared to other age groups.122

4.2

Prevalence of smoking among specific population groups

The generally declining trend in tobacco use in Australia masks stark differences in prevalence among some population groups. Groups with a higher prevalence of smoking include people who are socioeconomically disadvantaged, Aboriginal and Torres Strait Islander peoples, from some cultural backgrounds, in custodial settings, and suffering mental illness.38 4.2.1 Disadvantaged population groups

There is a strong social gradient evident in the prevalence of smoking, increasing as the level of socio-economic disadvantage increases.39 Moreover, the gap is widening, with smoking prevalence decreasing more rapidly among higher socio-economic groups.57 In Australia, as in other countries,123 income, the level of education and occupation (e.g. blue vs white collar) are markers of disparities in morbidity and mortality and the prevalence of smoking.124 For example, 33% of men and 28% of women in the most disadvantaged areas in Australia report being daily smokers, compared to 16% of men and 11% of women in the most advantaged areas.1 Children from disadvantaged households are also much more likely to be exposed to tobacco smoke at home.125 Tobacco use accounts for much of the higher mortality rates from CHD, stroke and chronic respiratory conditions observed among people who experience disadvantage.126 The greatest burden of illness and costs due to tobacco is born by households in the lowest quintile of social advantage.38,127 Smoking behaviour is often reinforced or compounded by other social determinants of health, such as stress, social isolation, unemployment and single parenting.38 Aboriginal and Torres Strait Islander peoples Aboriginal and Torres Strait Islander adults are more than twice as likely to smoke as non-Indigenous Australians.1 The prevalence of smoking among Aboriginal and Torres Strait Islander peoples varies with age and between communities, but overall, half of adult Aboriginal and Torres Strait Islander peoples (50%) were current daily smokers in 2004 2005, a figure that has not fallen in the last decade.1 There is little gender difference, with 51% of men and 49% of women reporting to be current daily smokers. Consequently, the damaging health effects of both active and passive smoking are greatly magnified in this population.128 Aboriginal and Torres Strait Islander peoples are up to eight times more likely to die from diseases caused by smoking when compared with the rest of the Australian population.129 Culturally and linguistically diverse communities Many people immigrating to Australia come from countries where the proportion of smokers is high. Overall, 16.9% of migrant people who arrived in Australia between 1996 and 2005 were daily smokers.1 However, there is huge variation within different ethnic communities. For example, the prevalence of smoking among men of Middle Eastern, southern European and some Asian backgrounds is significantly higher than in the general population.38 Cultural beliefs and attitudes and
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awareness of health risks are among factors that influence smoking behaviour among culturally and linguistically diverse communities.130, 131 People with mental illness Higher smoking prevalence has been reported for people with depression and anxiety disorders, with people with schizophrenia being three times more likely to smoke than those in the general population.132 Around 35% of smokers between 18 and 39 years of age reported some sort of mental health problem in an Australian survey.132 Tobacco cessation is complex for this population group, where smoking is sometimes used as a form of self-medication or a way of coping with difficult life circumstances and where there is a high level of addiction.133 Smokers with mental health conditions may also experience difficult withdrawal symptoms.125 Smoking in pregnancy The prevalence of smoking is relatively high among pregnant women, with an estimated 30% of Australian women being smokers134 when they fall pregnant and 23% smoking during pregnancy.135 Smoking in pregnancy among Aboriginal and Torres Strait Islander women is even higher: in peri-natal data collected from five Australian states and territories, 52.2% of Aboriginal and Torres Strait Islander mothers giving birth in 2003 reported smoking during pregnancy, compared with 15.8% of nonIndigenous mothers.136 Smoking cessation programs designed for pregnant women have been shown to increase the rates of smoking cessation, which benefits maternal and infant health and is cost effective.16 Smoking among young people More than 90% of Australians who currently smoke commenced the habit before they were 18 years of age.137 An Australia-wide secondary school students survey conducted in 2005 showed that 19% of males and 17% of females aged 17 years had smoked cigarettes at least once in the previous week.138 There are increasing concerns about disproportionate levels of smoking among some specific groups of the youth population, such as Aboriginal and Torres Strait Islander youth who have family members who smoke.139 Recent prospective evidence indicates that even a single smoking experience significantly increases the risk of smoking uptake in later adolescence.140

4.3

Attempts and desire to quit smoking

Most smokers want to quit smoking and wish that they had never started. Surveys indicate that more than 90% of smokers in Australia would like to quit.141 Due to the chronic nature of tobacco dependence, many smokers move through one or more periods of relapse before quitting successfully.142 At least 70% of Australian smokers are believed to be dependent on tobacco-delivered nicotine,38 and almost 80% of Australian smokers have unsuccessfully tried in the past to quit.141

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Effective approaches for tobacco control

The broad aim of tobacco control is to reduce smoking and its health consequences by: reducing uptake of smoking reducing consumption of tobacco promoting cessation of smoking protecting non-smokers from second-hand smoke.40 Tobacco-control advocates have long recognised the need for a comprehensive approach.41 International reviews consistently demonstrate that the most effective approaches to tobacco control are multifaceted and include a range of measures that complement and reinforce each other.42 46 From such evidence-based reviews, 10 core components of an effective approach to reducing the use of tobacco and its effects on health and society emerge (see Table 1). The impact of each strategy when it is used in isolation is likely to lead to an underestimate of their combined impact because of synergistic effects.42 Tobacco-control activity in Australia has occurred in all of these areas, and the current National Tobacco Strategy38 is essentially based on such a comprehensive approach. Table 1: 10 core components of a comprehensive approach to tobacco control 1. Taxation and pricing of tobacco products. 2. Regulation of tobacco advertising and promotion. 3. Regulation of product availability and sale of tobacco to minors. 4. Product regulation. 5. Hard-hitting mass-media campaigns (including paid and unpaid). 6. Education about the effects of smoking on health. 7. Support for cessation and prevention of relapse. 8. Health professional and healthcare system interventions. 9. Smoke-free policies and regulations. 10. Strategies to postpone or prevent the onset of smoking.

5.1

Taxation and pricing of tobacco products

Tobacco pricing and taxation is consistently identified as an important policy and economic strategy for comprehensive tobacco control.42,43 An analysis undertaken for the World Health Report 2002 goes so far as to describe tobacco taxation as the most cost-effective tobacco-control option in all regions of the world.143 Effective taxation policy needs to ensure that increases in the price of tobacco are real (i.e. not offset by increases in earning capacity), well publicised and occur as often as necessary to maintain effect.144 The use of tobacco is price sensitive, and real increases in the price of tobacco can reduce demand for cigarettes.145 Increases in the unit price for tobacco products are effective both in increasing smoking cessation and in reducing consumption.42,146 As the impact of price increases is particularly strong among young people,146,147 taxation policy to affect the cost of cigarettes is a critical strategy for reducing the uptake of smoking by young people and nicotine dependency.148 Optimally, the price of tobacco products should be regularly increased through taxation, at least in line with the cost of living.46

5.2

Regulation of tobacco advertising and promotion

Reducing exposure to tobacco advertising and promotion is a critical plank in tobacco-control efforts,42 particularly in relation to reducing the prevalence and uptake of smoking among young people.148 Young people s attitudes towards smoking and experimental inclinations have been shown to be
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strongly related to exposure to tobacco advertising and positive portrayals of smoking in the media.149,150 A recent study found that point-of-sale advertising and bold packaging displays in stores often visited by children can create a sense of familiarity with tobacco and predisposition to smoking.151 Health organisations internationally have called for measures to curb the portrayal of smoking in movies, including the imposition of an R rating, banning of brand images and placement of anti-tobacco advertisements before movie commencement.152 The mandate of the Commonwealth Tobacco Advertising Prohibitions Act (1992) is to limit the exposure of the public to messages and images that may persuade them to start smoking, continue smoking, or use, or continue using, tobacco products (Section 3). Internationally and within Australia, increasing restrictions on tobacco advertising, marketing and sponsorship has seen more tobacco industry resources directed towards package design, point-of-sale strategies and creative negotiation of benefits with retailers.153 155 Following increases in taxation, what the tobacco industry fears most is plain packaging of tobacco products and that they are to be stored under the counter and out of sight in all retail outlets.156 While the Tobacco Advertising Prohibitions Act has effectively eliminated many traditional forms of tobacco advertising and marketing, it has been less effective in deterring more under the radar communication strategies now being employed by tobacco companies in Australia. These include cigarette giveaways at youth concerts and nightclubs; online images and promotions; direct marketing and the use of databases; buzz marketing; and the promotion of smoking by broadcasters, publishers and film-makers.157 Despite submissions to the 2003 review of the Tobacco Advertising Prohibitions Act advocating for legislation to be tightened to address such strategies,157 the Commonwealth Government decided not to amend the Act.

5.3

Regulation of product availability and sale of tobacco to minors

The continuing widespread availability and ready access to tobacco products can send young people mixed messages about the social acceptability and dangers of smoking,38 and perceived availability has been linked to smoking uptake.158 The visible presence of tobacco products in a diversity of retail outlets is also detrimental to the addicted consumer,159 given the importance of temptation-avoidance in addiction treatment and cure. Product visibility and point-of-sale promotions can act as cues to smoke and stimulate purchases.160 Reducing access is a key component of effective programs to reduce smoking among young people,43,148,161 but needs to be supported by diligent enforcement and congruent community norms to be most effective.162 Licensing of tobacco retailers has been advocated as a means of further regulating the availability of tobacco and curbing sales to minors. The Federal Government commissioned a report to review the viability of licensing tobacco retailers and wholesalers in an Australian context,163 but to date licensing has been implemented only in some state jurisdictions. As young people s perceptions of the prevalence and acceptability of smoking are potentially influenced by the visibility of products164 displayed at point of sale, there have also been calls for retailers to stock cigarettes out of sight, such as under the counter or in overhead bins.46

5.4

Product regulation

A comprehensive approach to tobacco control includes regulation of the content, labelling and packaging of tobacco products. Graphic health warnings can be particularly effective in encouraging attempts at cessation165 and have been displayed in Australia on cigarettes manufactured after 1 March 2006. A recently published multi-country study found that large comprehensive warnings on cigarette packages are more likely to be noticed and rated by smokers to be effective.166 Some tobacco-control advocates have called for generic or plainer packaging to break down associations with brand imagery as the next step 167 in curbing the promotion of tobacco products. Cigarettes are highly toxic and cigarette smoke contains more than 4,000 chemicals, over 40 of which are known carcinogens.42 In spite of this, cigarettes are exempt in many countries from the consumer protection or regulator legislation that applies to food, drugs and other consumer products.46 There are increasing calls for regulation of tobacco products,168 encompassing permissible constituents of
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cigarettes, industry manipulation of product ingredients and design, and the development of fire-safe cigarettes. 5.4.1 New tobacco products

Smokeless tobacco products (snus or moist snuff) have been available in Sweden for many years and their use is considered to be, in part, responsible for lower rates of lung cancer in the male population of that country.169 However, research has shown that the use of snus is not without risk,170 and there are conflicting reports on whether the use of snus increases the risk of cardiovascular disease. The Heart Foundation is aware that the tobacco industry is planning to introduce new tobacco products to the Australian market and is actively lobbying the Australian Government to enable them to do so.171 Any request to introduce a new tobacco product to the Australian market should be approached from the perspective of presumption of harm . The onus should be on the individual or entity seeking to introduce the new product to provide evidence that its use by humans, over a period of 30 years at a level and in a pattern consistent with that likely to be observed in the general population, is not associated with increased risk to physical or mental health of any kind. Any new tobacco product that meets this standard should be subject to controls on promotion that are at least as strict as those currently prevailing in relation to other tobacco products already on the Australian market. Further, it is an evidence-based and established principle of tobacco control that the tobacco industry should not be permitted to advertise or market their products in any way.

5.5

Mass-media advertising (including paid and unpaid)

Hard-hitting mass-media campaigns are used to raise and personalise awareness of the health and social effects of smoking, motivate and support smokers to quit, and direct smokers to sources of assistance for cessation. They can also provide support for other tobacco-control strategies. Media campaigns can influence smoking-related knowledge, attitudes and the number of quit attempts.172,173 The mass media also has an important role to play in challenging attitudes, beliefs and complacency about smoking and keeping it alive as an issue in the minds of individuals and communities.46 There is compelling recent evidence from several US states for the effect of long-term, high-intensity, media-led campaigns in reducing the prevalence of smoking and/or the uptake of smoking.146,174,175 Mass-media campaigns are most effective when combined with other strategies and interventions.46,146,176

5.6

Education about the effects of smoking on health

There is evidence from a number of countries that publicising information about the harmful effects of smoking on health has resulted in sustained declines in tobacco consumption.145 As awareness of the effects of smoking on health increase in the population, this influence is likely to be more marginal,145 although research indicates that many smokers still discount the increased personal risk of heart disease and cancer they face from continuing to smoke.53 Other reasons why smokers may defer or reject quitting include misperceptions about the impact of smoking on quality of life, underestimating the relative risks of smoking, scepticism about health information or a belief that they can overcome the risks.177 In addition to the need for educational strategies that increase the salience and believability of health information about smoking, research continues to bring new evidence and information to light that needs to be communicated effectively to the public. Recent publicity in Australia about smoking and macular degeneration, impotence, and complications following surgery are pertinent examples. Information provision and education also has an important role to play in countering misconceptions held by smokers (for example relating to the safety of nicotine replacement therapy)178 and myths perpetuated by the tobacco industry (e.g. light cigarettes are healthier ).179 A number of the
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components of a comprehensive approach to tobacco control can serve as vehicles for communicating information about the effects of smoking on health to consumers, including mass media campaigns, school and community-based education initiatives, health professional training and resources, and warnings on tobacco packaging.

5.7

Support for cessation and prevention of relapse

While the majority of smokers want to quit, many are repeatedly unsuccessful in their attempts to give up due to the chronic nature of tobacco dependence.142 Tobacco-control efforts need to focus both on increasing the number of smokers who attempt to quit, and increasing the success rate of those attempts (i.e. preventing relapse).180 Given the high incidence of relapse in smoking cessation, strategies to help smokers overcome barriers to quitting, to gain access to social and other support, and to receive follow-up are an important adjunct to initial advice to quit.142 Strategies to support cessation range from self-help materials, counselling telephone lines and programs to pharmacological treatments. Cochrane reviews indicate various levels of success with such support strategies. Evidence-based reviews of smoking cessation interventions repeatedly confirm that the success of quit attempts is significantly increased by the use of pharmacological treatments for nicotine addiction (e.g. nicotine replacement therapy), with success rates further improved when combined with behavioural support.142,181 183 Australian smoking cessation guidelines now recommend that all smokers be offered pharmacotherapy (e.g. nicotine replacement therapy) to assist quitting, unless there is a contraindication.184 For smokers with less severe cardiovascular disease such as stable angina or a history of myocardial infarction, both nicotine replacement therapy185 and bupropion186,187 have been shown to be effective and safe. Two antidepressants, bupropion and nortriptyline, aid long-term smoking cessation, although there is no evidence that selective serotonin reuptake inhibitors (e.g. fluoxetine) effect smoking cessation success.188 Smokers uptake of pharmacological assistance in Australia remains suboptimal, with a recent review suggesting that a significant number of smokers hold misperceptions about the safety of nicotine replacement therapy and may consequently delay quitting or avoid using therapies that would increase their likelihood of success.178 Pregnant women are a case in point, with a recent paper in the British Medical Journal suggesting that nicotine replacement therapy during pregnancy is probably safer than smoking.189 Behavioural interventions/counselling can also increase the success of quit attempts,190 and telephone-based services are emerging as an effective means of supporting cessation efforts.191,192 There is increasing evidence that adolescent smokers can be addicted to nicotine.193,194 However, there are few effective youth cessation interventions in the literature.195,196 A recent Australian exception entails a whole-of-school approach that utilises school nurses in the delivery of cessation strategies.197,198 While the presence of withdrawal symptoms among adolescents who are trying to quit smoking supports the appropriateness of nicotine replacement therapy,199 some debate surrounds its acceptability, and ethical issues preclude controlled pharmacological trials with adolescent smokers.196

5.8

Health professional and healthcare system interventions

Reviews of best practice and evidence-based tobacco control concur about the importance of the health sector in encouraging and supporting cessation of smoking.42,142,176, 181,200 Health professionals have considerable contact with smokers, including patients presenting with smoking -related symptoms of disease.42,201 Advice to quit from health professionals is well respected and regarded, and evidence indicates that even brief advice from a doctor or other health professional can increase attempts at cessation and their success.181,202 Prevention of tobacco use, treatment and detection of disease should not be seen as an isolated health issue, but incorporated into related chronic disease programs, interventions and clinical care.44 This is particularly pertinent to prevention and management of cardiovascular disease. The occurrence of an acute cardiac event is recognised as a situation in which patients are receptive to advice regarding smoking cessation.21,22

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5.9

Smoke-free policies and regulations

Restricting smoking in public places protects non-smokers from second-hand smoke46,176 and can also contribute to a changing social norm with regard to smoking.203,204 The effectiveness of bans on smoking in public places and workplaces is supported in a recent Cochrane review of evidence, which notes that effectiveness is most likely when bans are comprehensive, supported by management and complemented by educational campaigns and other strategies.205 Smoke-free policies and legislation can significantly reduce exposure to second-hand smoke206 and protect those population groups most vulnerable to its associated risks, which include people with cardiac disease, children and infants, pregnant women and those with respiratory conditions.46 Smoke-free workplace policies can also encourage smokers to quit,46,207 increase chances of successful quitting208 and/or lead to fewer cigarettes being smoked.209 Australia has comparatively tough restrictions on smoking in work and public places, strengthened in recent years by the introduction of smoke-free restaurants, pubs and clubs in some states and territories, and a more widespread increase in the introduction of policies that prohibit smoking anywhere on workplace or public premises (e.g. public hospitals and health campuses). There are growing calls to promote smoke-free policies in non-public areas such as homes and cars, particularly in relation to protecting the health of babies and children.210,211 A recent US study found unsafe levels of second-hand smoke exposure for children who were passengers in cars with a smoker present.212

5.10 Strategies to postpone or prevent onset of smoking Approximately 90% of adult smokers began smoking before the age of 18 years.148 While there is debate as to the extent to which tobacco-control efforts should focus on prevention versus adult cessation, evidence supports the need for effective prevention interventions targeting children and youth,43,148,213 and discouraging adolescent experimental smokers from continuing to smoke.213,214 Effective youth smoking prevention requires a comprehensive multifaceted approach, involving a range of well-researched and coordinated strategies that complement and reinforce each other.215 219 One-off or single-focus interventions targeting young people are unlikely to have lasting results.220 Evidence from Australia and overseas substantiates the significant role that anti-smoking multimedia campaigns can play in reducing the prevalence of smoking among youth,221,222 both directly and to complement policy, community and settings-based strategies. There is mixed evidence regarding the effectiveness of school-based smoking interventions,220,223 225 and few studies have evaluated their long-term impact.221 At a minimum, school-based programs can delay the onset of smoking;214,226 this is still a positive public health outcome as mortality is lower and quitting rates are higher among smokers who commence smoking at a later age.223,226 School-based smoking prevention programs are more effective when they are comprehensive and complemented by other strategies214,218,223,227 and are multifaceted.228 Schools also provide access to important secondary target groups such as parents, families and the broader community.229

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Tobacco: the challenge for Australia

While Australia leads many countries in its progress in tobacco control, the prevalence of smoking and its impact on the health system and community remains a major public health challenge. In particular there remains the need to: accelerate the rates of decline in the prevalence of smoking among adults and young people reduce disparities in the prevalence of smoking among Aboriginal and Torres Strait Islander peoples, pregnant women, people who experience disadvantage, people with mental illness, prisoners and some cultural and linguistic groups help smokers to quit and avoid relapse secure sustained funding for tobacco-control campaigns and strategies elevate the priority given by the health system to support smoking cessation reduce exposure to second-hand smoke.

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7
7.1

A Heart Foundation response to tobacco

The potential impact of reductions in smoking on cardiovascular disease in Australia

Smoking is the most modifiable risk factor for cardiovascular disease in Australia. Reducing the prevalence of smoking and exposure to second-hand smoke can make a significant contribution to the primary prevention of cardiovascular disease.230 In addition, cessation of smoking is an important strategy for treatment and management of heart disease. While there are elevated risks for some cancers many years after cessation of smoking, quitting smoking can rapidly reduce the risk of heart disease and stroke.4 This can translate into considerable reductions in morbidity, mortality and costs associated with tobacco use. In the United States, for example, California s comprehensive tobacco-control program has accelerated declines in the prevalence of smoking and is estimated to have prevented 33,000 deaths from CHD during its first seven years.231 The cost of running California s comprehensive tobaccocontrol program has been offset by the short-term savings in direct medical costs associated with heart attacks and strokes prevented.101 This does not include longer-term gains in reduced cardiovascular risk or the impact of the reduced prevalence of smoking on other smoking-related disease, deaths and healthcare costs. In a US review of priorities among evidence-based clinical preventive services, cessation of smoking ranked second only to childhood vaccination in terms of cost effectiveness and its potential to reduce burden of disease.232 The National Health Priority Areas report on Cardiovascular Health233 computes the potential reduction in Australian rates of coronary events achievable through various prevention and treatment strategies. If the prevalence of smoking could be halved in Australia, there would be a 10% reduction in coronary events among the large proportion of the adult population (72%) with no existing evidence of heart disease or history of hypertension or high blood pressure, and reductions of 6 to 7% among those classified as having or being at higher risk of CHD.233 Overall, it has been calculated that, in Australia, more than 2,700 deaths each year from CHD could be avoided if the prevalence of smoking could be halved.111 The incidence of stroke could also be substantially reduced by lowering the prevalence of smoking, and cessation of smoking is a cost-effective strategy for continuing care,230 with the potential to prevent up to 1,400 recurrent strokes per year.233 Given the significant number of admissions to hospital and the cost of pharmaceutical treatment associated with cardiovascular disease in Australia, effective prevention of CHD can translate into substantial savings for the healthcare system.111,234

7.2

Strategy documents supported and endorsed by the Heart Foundation

The Heart Foundation recognises the need for a range of measures to build on the success achieved to date in reducing the number of people who smoke. This is reflected in the tobacco-control programs undertaken directly by the Heart Foundation or in partnership with other organisations, and in the Heart Foundation s advocacy on tobacco issues and policy matters. The Heart Foundation supports and has helped develop several key strategy documents pertinent to tobacco control. These include the: National Tobacco Strategy (2004 2009) National Strategy for Heart, Stroke and Vascular Health in Australia (2004) Guidelines for Preventing Cardiovascular Events in People with Coronary Heart Disease (2004) Framework Convention on Tobacco Control (2003). National Tobacco Strategy (2004 2009) The overarching goal of the current National Tobacco Strategy is to significantly improve health and to reduce the social costs caused by, and the inequity exacerbated by, tobacco in all its forms. The strategy has been endorsed by the Ministerial Council on Drug Strategy and the Intergovernmental Committee on Drugs. It has been ratified by the states and territories and has
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informed the development of tobacco plans/strategies at the jurisdictional level. It has also been endorsed by a range of non-government organisations, including the Heart Foundation. The objectives of the strategy, among all social groups, are to: prevent the uptake of smoking encourage and assist as many smokers as possible to quit as soon as possible eliminate harmful exposure to tobacco smoke among non-smokers reduce, where feasible, harm associated with continuing use of, and dependence on, tobacco and nicotine. At the time of this report the strategy represented a comprehensive and multi-pronged approach to tobacco control, as reflected in its seven key policy areas, outlined below. National Tobacco Strategy key policies 1. Regulation of tobacco: Intention of each policy To eliminate commercial conduct that promotes unnecessary, ill informed, non-voluntary and unnecessarily harmful use of and exposure to tobacco; and to ensure that the costs of addressing tobacco-related harm are borne by those who manufacture or sell tobacco rather than other Australian taxpayers To eliminate all promotion of tobacco products by those in the tobacco trade, and to discourage and address harm caused by other positive portrayals of smoking in the media To regulate supply so that tobacco products are available to adults who use them, but are not highly visible and are not sold to children To make tobacco products less affordable To eliminate exposure to environmental tobacco smoke indoors at work and in public places (and outdoors where mobility is limited) and to minimise it in residential institutions To mandate adequate and effective consumer information on tobacco products (and in the media and at point of sale) To coordinate regulation of tobacco products and products designed to replace tobacco, in ways that combine to reduce overall population harm To personalise the health risks of smoking and to increase people s sense of urgency about quitting and their awareness of effective therapies and contact details for services To ensure that all Australian smokers in contact with the healthcare system are identified and advised to quit, and that all smokers likely to have difficulty withdrawing from tobacco-delivered nicotine have access to support and appropriate and effective pharmacotherapies To contribute to efforts to prevent uptake by children, and to ensure that the community is well informed about smoking To reduce social alienation which, along with many other negative consequences, is associated with uptake and continuation of high-risk behaviours including smoking, and to invest in tobacco control as a key strategy for preventing and reducing social disadvantage To ensure access to information, treatment and services for people in highly disadvantaged groups who suffer a disproportionate level of tobacco-related harm

promotion

place of sale tax place of use

packaging products 2. Promotion of quit and smoke-free messages 3. Cessation services and treatment

4. Support for parents, carers and educators 5. Endorsement of policies that address causes of disadvantage 6. Tailoring initiatives for disadvantaged groups

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7. Research, evaluation, monitoring and surveillance

To ensure that research is conducted to assess needs and identify promising approaches and that systems are in place to assess efficacy and cost-effectiveness of programs and policies and the extent to which these are being achieved

National Strategy for Heart, Stroke and Vascular Health in Australia (2004) The National Strategy for Heart, Stroke and Vascular Health in Australia provides a blueprint for improving the cardiovascular health of Australians and reducing the prevalence of heart, stroke and vascular disease. The aims of the strategy in broad terms are to: progressively reduce the inequalities in health outcomes associated with heart, stroke and vascular disease, particularly through a focus on preventive and management practices in relation to Aboriginal and Torres Strait Islander peoples improve the care and management of heart, stroke and vascular disease across the continuum of care, to optimise the outcomes by identifying and promoting proven interventions support the dissemination and uptake of optimal preventive practices in relation to heart, stroke and vascular disease, and promote consistency in these practices enhance the role of consumers in maintaining and managing their own cardiovascular health. Tobacco control is relevant to all of these aims. Reducing smoking prevalence is recognised within the strategy as one of the most effective measures for preventing cardiovascular disease, but one that needs to be carried out across the life-stage continuum.230 Reducing risk in heart disease. Guidelines for preventing cardiovascular events in people with coronary heart disease (2004) These guidelines were developed by the Heart Foundation and Cardiac Society of Australia and New Zealand as a guide for all health professionals working to improve health outcomes for people with CHD. The goals relating to tobacco control advocate complete cessation and avoidance of exposure to second-hand smoke, and the recommended strategies reflect best practice principles for smoking cessation.90 The Framework Convention on Tobacco Control (2003) The Framework Convention on Tobacco Control is an international treaty that establishes international guidelines for tobacco control. This convention took more than three years to develop and was adopted at the World Health Assembly in May 2003 and came into force on 27 February 2005. It aims to achieve international collaboration and consistency in the war against tobacco. Targeted areas include complete prohibition of all direct and indirect forms of tobacco advertising, promotion and sponsorship; comprehensive tobacco product regulations (covering aspects such as manufacturing, packaging, ingredient disclosure and labelling); strong measures to combat tobacco smuggling; prominent picture-based health warnings on tobacco products; and the use of tobacco tax policy as a public health tool to achieve continuous declines in tobacco consumption.35 To date, 143 countries have ratified the treaty, including Australia.

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7.3

Key tobacco-control strategies advocated for and supported by the Heart Foundation

In suggesting the strategies detailed below, the Heart Foundation wishes to pursue activities that are complementary to the framework and key strategic areas provided by the National Tobacco Strategy (2004 2009). Key strategy area 1. Regulation of tobacco: promotion Strategies advocated by the Heart Foundation Obtain national agreement across jurisdictions to prevent the display of cigarette packs at the point-of-sale and elimination of point-of-sale advertising End all remaining forms of tobacco promotion, including bans on the promotion and positive portrayal of smoking that extend to all forms of media (including internet, films, video clips, etc) place of sale Advocate for amendments to the Commonwealth Tobacco Advertising Prohibitions Act (1992) to prohibit all new forms of promotional activity by the tobacco industry, including the sale of cigarettes to persons under 18 years via the internet Support moves for out of sight display of tobacco products in retail outlets Support measures to curb tobacco industry practices of mobile selling of cigarettes (e.g. from vans at workplaces, nightclubs) and cigarette girl hand-outs tax Increase tobacco excise to lower smoking rates and help ensure that cigarettes become less affordable to children Support the end of duty-free concessions for tobacco products Advocate for prevention of evasion of customs and excise duty on tobacco products place of use (smoke-free policies) National agreement across jurisdictions for the extension of smoke-free legislation to cover all government agencies and sites, as well as the campuses of all education institutions and health services and hospitals Encourage governments to extend or develop legislation to mandate smoke-free workplaces and public places, including outdoor areas such as restricted seating, near air-conditioning intakes and near doorways Support Action on Smoking and Health (ASH) and other health organisation advocacy for smoke-free homes and cars for children Encourage local councils to ban smoking within 10 metres of all children s playground equipment; around all playing fields and sporting grounds; and to erect signage around playground equipment and playing fields to indicate that these designated areas are smoke free; and ensure that events run or sponsored by local councils should be smoke free Encourage local councils to introduce bans on smoking in other areas falling within their jurisdiction, such as beaches, non-residential building entrances Urge local governments and other organisations to have no association with British American Tobacco s Butt Littering Trust as its promotion of responsible management of cigarette butts detracts from the need for smoke-free areas and allows the tobacco industry opportunity to polish its public image

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Key strategy area packaging

Strategies advocated by the Heart Foundation Full information disclosure on all additives used by manufacturers to be disclosed to consumers and the public Prohibit the use of misleading terms such as mild and light as well as the use of colours and other packaging traits in the marketing of tobacco products Encourage the introduction of tobacco packaging requirements that include generic packaging and pack inserts that will help to reduce smoking uptake, prevent relapse and maximise quitting intentions

products

Regulate tobacco to prevent the use of additives that make tobacco smoke more palatable and addictive, especially for children Any request to introduce a new tobacco product to the Australian market should be approached from the perspective of presumption of harm , with the onus on the individual or entity seeking to introduce the new product to provide evidence that its use by humans over a period of 30 years at a level and in a pattern consistent with that likely to be observed in the general population is not associated with increased risk to physical or mental health of any kind. Any new tobacco product that meets this standard should be subject to controls on promotion that are at least as strict as those currently prevailing in relation to other tobacco products already on the Australian market Legislation that will require tobacco products to meet the proposed reduced ignition-propensity standards The tobacco industry and associated interests should not be permitted to make or publish any explicit or implicit health claims about present or new products, whether via advertising or any other form of communication with the public or consumers Ensure complete and effective disclosure by tobacco companies of information pertaining to product contents and toxic outputs, marketing activities, health risks and sales

2. Denormalising of smoking

Advocate for reclassification to MA or R of movies that contain smoking and placement of counter advertising before movies that show smoking Reward health behaviour by working with health and life insurers to provide genuine premium discounts for non-smokers and other incentives to healthy behaviour Deny tobacco industry access to any government subsidies or incentives, such as research and development grants Require disclosure by political parties and politicians of all donations from tobacco companies or organisations affiliated with tobacco companies Publicly expose the history of unlawful conduct of the tobacco companies (including through the discovery of incriminating industry documents) and demonstrate the ongoing effects of that conduct Support litigation and other measures to hold the tobacco companies accountable for the effects of their unlawful conduct, and require them to compensate those who have already been harmed, and to take positive steps to reduce the likelihood of future harm caused by this conduct

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Key strategy area 3. Promotion of quit and smoke-free messages

Strategies advocated by the Heart Foundation Re-instigate a National Tobacco Campaign (education and information campaign) funded by a modest increase in federal tobacco excise Re-establish an expert Ministerial Tobacco Advisory Group, comprising leading tobacco-control experts, working directly with the Federal Minster for Health and Ageing. The advisory group would guide the implementation of the National Tobacco Campaign Lobby governments to ensure that policy measures to prevent tobacco use are included in all federal and state drug policy strategies Encourage the Federal Government to include reduction of tobacco use as a priority in all relevant national health strategies Ensure long-term financial commitments to tobacco-control funding, including mass-media campaigns designed according to sound behavioural principles and market research, by identifying potential funders (governments, business, health sector) and potential sources of funding (licence fees, litigation, taxation)

4. Cessation services and treatment

Support and encourage cardiologists, GPs and other health professionals in contact with heart patients to more proactively advise and assist them to quit smoking Encourage professional and disease-specific associations and organisations to develop evidenced-based guidelines and clinical protocols that include advice to quit, appropriate referral to cessation services and prescription products for all health professionals Advocate for the routine offering of cessation advice, counselling and tobacco dependence treatment to all patients who smoke who are admitted to hospitals and in-patient services Encourage government to include referral and follow-up of smokers to specialist tobacco-dependence treatment services on the Medicare Schedule Establish a system to regulate the promotion and sale of all products that deliver nicotine in line with the development of improved pharmacological aids to quitting Liaise with government to engage in strategic negotiations with pharmaceutical companies to ensure that deregulation of nicotine replacement therapy and other cessation products is accompanied by commitment to product innovation assistance to address broader tobacco-control goals

5. Support for parents, carers and educators

Encourage parents and schools to give clear and consistent messages and enforce clear and consistent rules about smoking Support the inclusion of smoking in drug education delivered in school and other settings to young people and parents Ensure evidence-based and relevant advice is available to parents and other carers of young people who are smoking

6. Endorsement of policies that address causes of disadvantage

Support policies that fund programs and strategies that address social determinants of health relevant to smoking. These include education, family support, recreation and welfare policies, and mental health promotion
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Key strategy area 7. Tailoring initiatives for disadvantaged groups

Strategies advocated by the Heart Foundation Funding of dedicated tobacco-control programs for Aboriginal and Torres Strait Islander peoples and high-risk groups (e.g. those with mental illness) Sustained funding to support a coordinated tobacco-control campaign for Aboriginal and Torres Strait Islander peoples Support implementation of the recommendations of the Centre for Excellence in Indigenous Tobacco Control235 for improving and strengthening Aboriginal and Torres Strait Islander tobacco control. Such measures include: o o o improving representation of Indigenous people on boards, advisory groups and in partnerships in tobacco control tobacco control training for Aboriginal health workers development of Aboriginal and Torres Strait Islander research capacity in tobacco

Advocate for all visitors arriving in Australia to be informed that Australia promotes and requires smoke-free environments, and that visitors who are smokers can obtain smoking cessation products which are widely available in pharmacies 8. Research, evaluation, monitoring and surveillance Advocate for continuing and targeted investment in tobacco-control research, population prevalence monitoring and campaign evaluation at national, state and territory level Continue to support the development of tobacco-control research and studies through Heart Foundation research funding programs

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Appendix
National Tobacco Control Committee: Policy statement on products entering the tobacco market

Background 1. The Australian tobacco market is dominated by a combination of manufactured cigarettes and loose tobacco for roll-your-own cigarettes. 2. Half of cigarette smokers who continue to smoke are killed prematurely by their smoking. This makes smoking a uniquely dangerous habit. 3. Primary pipe or cigar smokers meaning individuals who have only ever smoked pipes or cigars have a reduced risk of premature death and avoidable disease compared with smokers of cigarettes or smokers of cigarettes who have later switched exclusively to a pipe or cigars. However, primary pipe and cigar smokers still have a significantly increased risk of developing cancer of the lip, mouth and tongue.

4. The sale of smokeless tobacco products such as inhaled snuff, chewing tobacco, and oral snuff (or snus ) is currently prohibited in Australia. 5. Tobacco companies have a history of formal conviction for misleading and deceptive conduct in a number of jurisdictions, including Australia. 6. There is abundant peer-reviewed, scientific evidence to show that smokers smoke cigarettes in systematically different and potentially more hazardous ways compared with the laboratory machines used for formal standardised assays of the yields from manufactured cigarettes. 7. It is accepted in the medical and scientific community that smoking causes cardiovascular disease in all principal arterial territories coronary, cerebral, aortic and lower limbs even though the constituent or constituents of tobacco smoke responsible for this increased risk of arterial disease remain to be conclusively defined. 8. Smoking causes around 7500 deaths from cardiovascular disease in Australia each year close to one death every hour. 9. It has been repeatedly demonstrated that rates of lung cancer in a community correlate most closely with the pattern of smoking in that population 20 to 30 years previously. 10. When an individual stops smoking, it takes at least five years for them to lose the excess risk of heart attack and stroke associated with smoking. Policy Any request to introduce a new tobacco product to the Australian market should be approached from the perspective of presumption of harm . The onus should be on the individual or entity seeking to introduce the new product to provide evidence that its use by humans over a period of 30 years at a level and in a pattern consistent with that likely to be observed in the general population is not associated with increased risk to physical or mental health of any kind. Any new tobacco product that meets this standard should be subject to controls on promotion that are at least as strict as those currently prevailing in relation to other tobacco products already on the Australian market. Further, it is an evidence-based and established principle of tobacco control that the tobacco industry should not be permitted to advertise or market their products in any way.
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