Smokeless tobacco use in Australia

Trends in nicotine consumption between 2010 and 2017 in an Australian city using the wastewater-based epidemiology approach

Monitoring smoking prevalence is key to assessing responses to tobacco control measures, and evaluating associated health and economic costs. Estimates of tobacco consumed in Australia are based on various data sources - tax excise clearances, sales, and self-report surveys. There are limitations with each of these data sources which makes triangulation of cigarette use estimates by multiple methods important. Wastewater-based epidemiology, the systematic sampling and analysis of wastewater, is now a routine method to measure and monitor human exposure to a range of chemicals. This study provides a high frequency long-term temporal assessment of exposure to nicotine, the main addictive component of tobacco, using this approach. 291 archived wastewater samples collected from a regional city catchment from 2010 to 2017 were analysed for human-specific nicotine metabolites (cotinine and trans-3'-hydroxycotinine), to estimate per capita nicotine use. Temporal trends in nicotine use determined by wastewater-based epidemiology were compared with national sales and survey data. Wastewater analysis showed a 25% reduction in the mean number of cigarette equivalents consumed from 2010 to 2017, representing a 3% annual decline. These findings are in good agreement with estimates based on surveys and sales data, indicating annual declines of 5% and 4%, respectively. Findings of this study demonstrate WBE to be a relatively cost-effective and objective approach to reporting long-term data on nicotine consumption. When combined with alternative data sources, and valuable sociodemographic information of surveys, wastewater-based epidemiology helps to refine our estimates and understanding of the total impacts of smoking.

Tobacco smoking and all-cause mortality in a large Australian cohort study: findings from a mature epidemic with current low smoking prevalence

BACKGROUND

The smoking epidemic in Australia is characterised by historic levels of prolonged smoking, heavy smoking, very high levels of long-term cessation, and low current smoking prevalence, with 13% of adults reporting that they smoked daily in 2013. Large-scale quantitative evidence on the relationship of tobacco smoking to mortality in Australia is not available despite the potential to provide independent international evidence about the contemporary risks of smoking.

METHODS

This is a prospective study of 204,953 individuals aged ≥45 years sampled from the general population of New South Wales, Australia, who joined the 45 and Up Study from 2006-2009, with linked questionnaire, hospitalisation, and mortality data to mid-2012 and with no history of cancer (other than melanoma and non-melanoma skin cancer), heart disease, stroke, or thrombosis. Hazard ratios (described here as relative risks, RRs) for all-cause mortality among current and past smokers compared to never-smokers were estimated, adjusting for age, education, income, region of residence, alcohol, and body mass index.

RESULTS

Overall, 5,593 deaths accrued during follow-up (874,120 person-years; mean: 4.26 years); 7.7% of participants were current smokers and 34.1% past smokers at baseline. Compared to never-smokers, the adjusted RR (95% CI) of mortality was 2.96 (2.69-3.25) in current smokers and was similar in men (2.82 (2.49-3.19)) and women (3.08 (2.63-3.60)) and according to birth cohort. Mortality RRs increased with increasing smoking intensity, with around two- and four-fold increases in mortality in current smokers of ≤14 (mean 10/day) and ≥25 cigarettes/day, respectively, compared to never-smokers. Among past smokers, mortality diminished gradually with increasing time since cessation and did not differ significantly from never-smokers in those quitting prior to age 45. Current smokers are estimated to die an average of 10 years earlier than non-smokers.

CONCLUSIONS

In Australia, up to two-thirds of deaths in current smokers can be attributed to smoking. Cessation reduces mortality compared with continuing to smoke, with cessation earlier in life resulting in greater reductions.

Trends in alternative tobacco use among light, moderate, and heavy smokers in adolescence, 1999-2009

OBJECTIVE

To examine trends in alternative tobacco product (ATP) use (smokeless tobacco, cigars, and bidis/cloves) among a national sample of adolescent cigarette smokers (light, moderate, and heavy) during 1999-2009.

METHOD

A secondary analysis of data from the 1999-2009 National Youth Tobacco Survey was performed to investigate the tobacco behaviors of 6th through 12th graders enrolled in public and private schools in the United States. Long-term trends in ATP use were analyzed using logistic regression--controlling for sex, grade, and race/ethnicity--and simultaneously assessing linear and higher order time effects and their interaction with cigarette smoking status.

RESULTS

During 1999-2009, increases in smokeless tobacco use and decreases in bidis/cloves use were observed across all smoking groups. For cigars, declines were observed for heavy and moderate smokers, but levels returned to baseline levels in 2009. Cigar use among light smokers was less variable. Rates of any ATP were highest among heavy smokers and lowest among light smokers.

CONCLUSION

Trends in cigarette and SLT use increased dramatically in the past decade, and this increase is evident across all cigarette smoker types. Implications for tobacco surveillance, prevention and cessation programs, and tobacco control policies are discussed.