Australia has  a decline in smoking rates . Despite this,  there are still over 20,000 deaths attributed to smoking each year.

1. Smoking Rates:

While there is a decrease in smoking rates in Australia, the annual toll from smoking-related deaths remains high, surpassing 20,000.

2. Tobacco Smoke and Heart Disease:

Tobacco smoke stands out as a primary risk factor for heart disease, contributing to 12% of the burden, encompassing both death and illness, related to cardiovascular disease in Australia.

According to the data from Australian Institute of health and Welfare (AIHW), Australia has played a prominent role in global tobacco control efforts and boasts one of the world’s lowest daily smoking rates, standing at 12.2% currently. Despite national objectives aiming to reduce daily smoking to below 10% and halve the Aboriginal and Torres Strait Islander adult daily smoking rate by 2018, these targets were not met. Notably, specific demographic groups, such as individuals with mental illness, continue to exhibit elevated smoking rates. As per an article from AIHW in 2015 on the impact and causes of illness and death in Australia, tobacco smoking remains the predominant behavioural risk factor contributing to a substantial disease burden, with almost 21,000 deaths directly attributed to smoking in Australia in 2015. Particularly concerning are the severe adverse effects of smoking during pregnancy on both maternal health and foetal development.

To address this critical issue, it is imperative to encourage and support individuals who smoke and/or vape in their journey to quit. The recommended first-line approach for smoking cessation involves a multi-session behavioural intervention, coupled with clinically appropriate pharmacotherapies approved by the Therapeutic Goods Administration.

Zwar, N. (2020). Smoking cessation. Australian Journal of General Practice. https://www1.racgp.org.au/ajgp/2020/august/smoking-cessation-1

In an effort to reduce smoking in Australia, here are seven proposed steps which are in place:

1. At present, smoking is made less affordable:

   – Price hikes on tobacco products emerge as the most effective single measure for preventing and decreasing tobacco use.

   – Elevated prices serve to dissuade non-smokers from initiating smoking, motivate existing smokers to quit, and deter former smokers from resuming the habit.

   – Advocacy for a sustained commitment from the Commonwealth Government to implement ongoing price increases on tobacco products is a priority for the Heart Foundation.

Efforts to curb smoking and regulate tobacco use are critical for public health, emphasizing the significance of both behavioural interventions and policy measures to mitigate the substantial health risks associated with smoking.

1. Mass media and public education campaigns:

Utilizing mass media and public education campaigns proves to be an effective means of conveying the dangers of tobacco and encouraging individuals to attempt quitting. The Australian government strongly advocates for substantial investments in both national and state media campaigns aimed at educating all Australians about the hazards of tobacco smoke.

Recent campaigns include:

– Make Smoking History (WA)

– Quit Stalling NSW and Tasmania

– Don’t Make Smokes Your Story (a national campaign with Aboriginal and Torres Strait Islanders as the primary focus group).

2. Support to quit smoking:

Individuals are exposed to campaign messages that motivate them to cease smoking, persist in quitting efforts, and understand compelling reasons never to initiate smoking. Various forms of support are available to aid in smoking cessation, recognizing the common occurrence of individuals quitting for a period and then relapsing.

Support is essential to encourage quitting and assist those who successfully quit in remaining non-smokers for life. We endorse health professionals in all settings who inform their patients about the cardiovascular disease risks associated with smoking and the immediate and long-term health benefits of quitting.

Multiple resources are available to support smoking cessation, including:

– Quitline 13 78 48

– Websites: [www.quitnow.gov.au](www.quitnow.gov.au) & [www.quit.org.au](www.quit.org.au)

– Online tools: Heart Foundation Quit Smoking Action Plan and Quit Coach

– Mobile apps: My Quit Buddy and Quit for You-Quit for Two.

Smoking and tobacco regulation advocacy | The Heart Foundation. (n.d.). Heartfoundation-Prod.azurewebsites.net. Retrieved November 12, 2023, from https://www.heartfoundation.org.au/bundles/get-involved/advocacy-smoking-and-tobacco-regulation#:~:text=We%20support%20health%20professionals%20in

3. Increasing the number of smoke-free environments:

Smoke-free environments contribute to heart health by reducing exposure to second-hand smoke, decreasing cigarette consumption, encouraging smoking cessation, and normalizing non-smoking. Immediate and long-term risks for heart disease are associated with exposure to second-hand smoke. There is a robust smoke-free legislation in place and government is working towards making all public places and popular outdoor venues, such as dining and drinking areas, completely smoke-free.

Benefits of health and economy as a result of the smoke-free environments:

 – It has been seen that there is a reduced cardiovascular disease, especially a decrease in admissions to hospitals for heart attacks

– An improved respiratory health, particularly reduced incidences of asthma and symptoms has been observed

– Communities have been experiencing a 15% drop in Acute Myocardial Infarction (AMI) hospital admissions during the first year of smoke-free legislation, reaching a 36% decline by the third year after implementation, with younger and non-smoking populations experiencing the greatest declines.

– Small positive effects on businesses, including restaurants and bars

– Increased worker productivity

– Reduced cleaning and maintenance costs

– Reduced insurance costs

Smoke-free housing is supported, emphasizing the right of all Australians to breathe clean air, especially within their homes. Efforts in Queensland calling for changes in strata housing processes to provide better protection from smoke infiltration are endorsed.

For additional information on smoke-free environment laws and regulations across Australia, we can read the refer to a very helpful document from Economics of Tobacco and Tobacco Control 2016.

4. Restricting commercial promotion of smoking:

Point-of-sale tobacco advertising and product display are prohibited in Australia. Federal, state, and territory laws acknowledge the well-established negative effects of tobacco marketing and promotion on smokers, recent quitters, and youth.

The introduction of plain packaging in Australia in 2012 eliminated another significant avenue for the promotion of tobacco products.

Pricing displays for cigarettes

 In the realm of tobacco, price boards serve as a notable avenue for showcasing tobacco products and providing discounts on prices.

Price boards continue to stand as one of the limited means of tobacco promotion in New South Wales, the Northern Territory, South Australia, Tasmania, Victoria, and Western Australia.

An examination of tobacco retailers in Melbourne revealed a strategic use of price boards to promote specific brands and introduce new products.

In Queensland and the Australian Capital Territory, the use of price boards is not allowed. Consumer communication regarding prices is to be confined to informational sheets available to adult smokers upon request at the point of sale.

5. Controlling the contents of cigarettes and smoking related products:

Tobacco is the most harmful ingredient of a cigarette, in both factory-made or roll-your-own (RYO). Additional features, such as filters and additives, used to make tobacco products more appealing are also harmful. There are emerging evidence of how the tobacco industry manipulates cigarette design, packaging and labelling to recruit new smokers and retain current smokers. 

Cigarette Filters

In Australia, about 90% of cigarettes are equipped with filters that introduce fresh air into the smoke when a smoker inhales. This dilution process adds variation to taste strength and diminishes harshness or irritation, enhancing the overall smoking experience. To diminish the allure of tobacco products, the inclusion of filter ventilation should no longer be allowed in Australia. For additional details on cigarette filters, refer to the provided resources.

 Tobacco Additives

Cigarette additives serve various purposes, including enhancing flavour and aroma, regulating burn rates, managing nicotine delivery and harshness, and extending shelf life.

To effectively curb the appeal of tobacco products, especially to young individuals, there is a need for more comprehensive and consistent regulations, particularly regarding the prohibition of sweet, fruity, and menthol-flavoured smoking products. The Canadian government has already taken steps by banning menthol in most tobacco products to reduce the attractiveness of smoking to Canadian youth. Further information on tobacco additives, including menthol, is available for reference.

6. By limiting the accessibility of tobacco:

Tobacco continues to be among the easily accessible consumer goods, subject to minimal restrictions on sales personnel and points of purchase. The extensive availability raises concerns due to the following reasons:

– Areas characterized by social and financial disadvantage tend to have a higher concentration of cigarette sellers.

– The ease of tobacco accessibility heightens the likelihood of relapse for individuals attempting to quit smoking.

– The prevalence of tobacco vendors contributes to the normalization of smoking and undermines other initiatives aimed at tobacco control.

Quitting smoking:

1. Establish a Quit Date:

The American Cancer Society (ACS) suggests setting a quit date as a mental preparation strategy for quitting (‘Guide to Quitting Smoking,’ 2022).

Quit Tobacco | How To Quit Smoking or Smokeless Tobacco. (n.d.). Www.cancer.org. https://www.cancer.org/cancer/risk-prevention/tobacco/guide-quitting-smoking.html

2. Seek Support:

   – The Centers for Disease Control and Prevention (CDC) stresses the significance of seeking support from friends, family, and support groups to enhance the chances of a successful quit attempt (“How to Quit Smoking,” 2022).

CDC. (2019, August 2). How to quit smoking . Centers for Disease Control and Prevention.https://www.cdc.gov/tobacco/campaign/tips/quit-smoking/index.html

3. Identify Your Triggers:

   – The National Institute on Drug Abuse (NIDA) emphasizes the importance of recognizing smoking triggers as a critical step in quitting, suggesting the development of alternative coping strategies (“What to Do If You Relapse,” 2022).

How to Help Someone Quit Smoking. (n.d.). Www.cancer.org. https://www.cancer.org/cancer/risk-prevention/tobacco/helping-a-smoker-quit.html

4. Substitute Smoking with Healthier Habits:

   – The American Lung Association recommends replacing smoking with healthy activities, such as exercise, to manage cravings (“How to Quit Smoking,” 2022).

Quit Tobacco | How To Quit Smoking or Smokeless Tobacco. (n.d.). Www.cancer.org.https://www.cancer.org/cancer/risk-prevention/tobacco/guide-quitting-smoking.html

5. Consider Nicotine Replacement Therapy (NRT):

– Nicotine Replacement Therapy (NRT) comes in an extended-release format, such as the nicotine patch, and various faster-acting oral forms like gum, lozenge, inhalator, mouth spray, and oral strip. The effectiveness of NRT as a standalone treatment is moderate, showing a 6% improvement in quit rates over a period of 6–12 months compared to a placebo.

West, R., Raw, M., McNeill, A., Stead, L., Aveyard, P., Bitton, J., Stapleton, J., McRobbie, H., Pokhrel, S., Lester-George, A., & Borland, R. (2015). Health-care interventions to promote and assist tobacco cessation: a review of efficacy, effectiveness and affordability for use in national guideline development. Addiction, 110(9), 1388–1403. https://doi.org/10.1111/add.12998

 6.  Prescription Medications:

It has been seen that medical treatment can aid people dependent on nicotine in their efforts to quit smoking. Your doctor would recommend medications for quitting smoking as an initial option. This has an emerging strong evidence of both effectiveness and safety, approved in Australia for smoking cessation. These options include various forms of nicotine replacement therapy (NRT), varenicline, and sustained-release bupropion. According to the pools of data from several scientific studies, a medication known as VARENICLINE or a combination of nicotine replacement therapy (utilizing both patch and rapidly acting forms), when combined with brief advice and guidance from a professional, nearly triples the likelihood of successful quitting compared to a treatment with an inactive ingredient after six months. Monotherapy with bupropion or NRT, accompanied by brief counselling, almost doubles the odds of quitting compared to a placebo at the six-month follow-up. Present evidence suggests that varenicline and combination NRT exhibit similar effectiveness, surpassing NRT monotherapy or sustained-release bupropion.

Zwar, N. (2020). Smoking cessation. Australian Journal of General Practice. https://www1.racgp.org.au/ajgp/2020/august/smoking-cessation-1

      7. Plan for Cravings:

   – The National Cancer Institute (NCI) advises employing distraction techniques such as deep breathing and exercise to manage cravings (“Managing Cravings,” 2022).

Here are some tips for managing cravings:

• Consider using nicotine replacement items or consult your doctor for alternative medications.
• Reassure yourself that cravings are temporary and will fade away.
• Steer clear of situations and pastime activities linked to using tobacco.
• As an alternative to smoking, experiment with nibbling on carrots, pickles, apples, celery, sugarless gum, or hard candy. Keeping your mouth engaged might help alleviate the psychological urge to smoke.
• Practice this technique: Inhale deeply through your nose and exhale slowly through your mouth. Repeat this process 10 times.

National Cancer Institute. (2022, January 3). Handling Withdrawal Symptoms & Triggers When You Decide to Quit. National Cancer Institute; Cancer.gov. https://www.cancer.gov/about-cancer/causes-prevention/risk/tobacco/withdrawal-fact-sheet

8. Stay Positive:

   – The World Health Organization (WHO) underscores the numerous benefits of quitting smoking, leading to improved health and a longer life (“Tobacco,” 2022).

World Health Organization. (2023, July 31). Tobacco. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/tobacco

     9. Avoid Triggers:

   – According to the British Heart Foundation (BHF), a key strategy in quitting is to steer clear of situations that trigger smoking urges (“How to Quit Smoking,” 2022).

How to quit smoking. (n.d.). Www.bhf.org.uk. https://www.bhf.org.uk/informationsupport/heart-matters-magazine/wellbeing/resolutions/quit-smoking

Electronic Nicotine Delivery System (ENDS) constituents:

Although electronic nicotine delivery systems (ENDS) do not include or entail the burning of tobacco, they produce harmful substances commonly found in the smoke of conventional cigarettes. These elements are generally present in much lower concentrations and can vary significantly based on the specific device and the liquid used. The potential additive or synergistic effects of these components are presently unclear

Vape liquids

Vape liquids or E-liquids typically consist of a blend of propylene glycol, glycerine, nicotine, and flavouring agents. Although propylene glycol and glycerine are deemed safe for oral consumption, their exposure to high temperatures during vaping can lead to the formation of harmful substances. The diverse array of flavouring agents significantly influences the composition of both the e-liquid and the resulting aerosol, potentially introducing substances not found in traditional cigarettes. While many flavouring agents are considered safe for ingestion, there is limited data on their safety when inhaled. Notably, certain flavouring agents like cinnamaldehydes are recognized as toxic when inhaled.

Electronic cigarette vapours

The content of the vapor is contingent upon the specific devices and e-liquids in use. Elements like nicotine, carbonyl compounds, particulate matter, metals, volatile organic compounds, and tobacco-specific nitrosamines are consistently identified in emissions from e-cigarettes. The existence of these elements raises concerns about the potential health risks for both e-cigarette users and those in close proximity.

Nicotine

Contemporary e-cigarettes have the capacity to provide nicotine concentrations similar to those found in conventional cigarettes. Nicotine is directly linked to the onset of cardiovascular diseases, leading to elevated heart rate, blood pressure, and vasoconstriction. Research has revealed that this compound can trigger inflammation, endothelial dysfunction, angiogenesis, lipogenesis, and atherosclerosis. Nicotine is widely acknowledged as a strongly addictive substance, and the concentrations dispensed by contemporary e-cigarettes have the capability to initiate and sustain dependence. It also has the potential to impact brain development, posing particular risks for infants, adolescents, and pregnant women.

Carbonyl compounds

Very toxic chemical called carbonyl compounds like acetaldehyde, formaldehyde, and acrolein are generated through the heat-induced breakdown of propylene glycol and glycerine. These aldehydes have cardiovascular impacts, leading to oxidative stress and inflammation. Acrolein, specifically, is associated with endothelial dysfunction, vascular damage, platelet activation, and atherosclerosis. Contemporary e-cigarettes have the capacity to produce comparable amounts of carbonyl compounds to those emitted by traditional tobacco cigarettes.

Particulate matter

1. Fine and Ultrafine Particulate Matter in E-Cigarettes

Fine (PM2.5) and ultrafine (PM0.1) particulate matter, particles with diameters of < 2.5 μm and < 0.1 μm, respectively, have the potential to enter the general circulation through the lungs. These particles are linked to cardiovascular diseases and are found in quantities comparable to traditional cigarettes.

2. Health Implications of PM2.5 Exposure from Modern E-Cigarettes

Exposure to PM2.5 from modern e-cigarettes can contribute to the development of hypertension, oxidative stress, endothelial dysfunction, atherosclerosis, arrhythmia, coronary artery disease, and myocardial infarction. Notably, PM2.5 is also present in second-hand smoke exhaled by e-cigarette users, highlighting its significance in public health, as even minimal exposure levels may pose harm.

Heavy Metals Presence in E-Cigarettes

Different studies have identified various types and amounts of metals in e-cigarettes. Due to this variability, the contribution of these metals to the development of cardiovascular diseases is still under evaluation.

Second-hand Exposure to E-Cigarette Aerosols

Users of e-cigarettes visibly release aerosols with nicotine and harmful components into the air, despite these devices not producing side-stream smoke. Substantial evidence suggests that indoor air quality can be impacted by e-cigarettes, leading bystanders to inhale aerosols and their components to some extent.