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Indonesia on track to having world’s highest smoking rates

With few commitments to curb cigarette consumption, Indonesia is poised to have the largest population of smokers in the world in the next decade.

Currently, the country ranks fourth on the list of countries with the most smokers, behind China, Russia and the US. But while other heavy-smoking countries are enforcing tough tobacco controls, Indonesia is planning to double tobacco production.

Indonesia already has the world’s highest smoking prevalence among males, as 67.4 percent of males over 15 years old smoke. The cost of treating tobacco-related diseases in the country is currently estimated to reach Rp 11 trillion (NZ$1.21 billion) a year, 0.29 percent of the country’s gross domestic product (GDP).

“If we don’t prevent and control the impacts of smoking, then there’s a chance we will become the world’s largest tobacco consumer in the next 10 years,” the Health Ministry’s disease control director general, Muhammad Subuh, said during an event to mark World No Tobacco Day.

The governments of China, Russia and the US have realised that health costs and other hidden expenses resulting from smoking are far higher than the money generated from the tobacco industry.

A study published last year in The Lancet medical journal said that a third of all men currently under the age of 20 in China, the world’s largest tobacco producer and consumer, would die prematurely if they did not give up smoking.

Therefore, China signed the World Health Organisation’s (WHO) Framework Convention on Tobacco Control (FCTC) in 2006. Since then, the Chinese government has worked earnestly to implement the FCTC by adopting a series of measures to control the tobacco epidemic.

Loose controls

Even though tobacco-related diseases claim 200,000 lives in Indonesia every year, the government has refused to sign the FCTC, resulting in loose cigarette controls and the country being dubbed the tobacco industry’s playground.

Like China, Russia and the US have also taken steps to ensure that the tobacco industry does not endanger the future of their young generations.

“We’ve seen changes taking place in countries with very difficult, complex environments. For example, Russia. It now has one of the strongest tobacco control laws in the world. If you had asked us 10 years ago whether Russia would be where they are, we would’ve said it’s very difficult as the industry is very active,” World Lung Foundation senior vice-president of communications Sandra Mullin told The Jakarta Post.

Russia signed the FCTC in 2008 and introduced a comprehensive tobacco control law in 2013, effectively banning advertising of tobacco products as well as sponsorship of events by tobacco companies.

The law aimed to reduce the number of annual tobacco-related deaths from 400,000 to 150,000-200,000.

The US, meanwhile, saw its smoking rates hit an all-time low in 2014, with only 16.8 percent of adults smoking, after it passed the Tobacco Control Act into law in 2009.

The law also bans sales of cigarettes to minors and tobacco-brand sponsorship of sports and entertainment events or other social and cultural occasions.

Conversely, the Indonesian government has only made minor efforts to tone down tobacco campaigns. Since 2015, it has banned tobacco advertising in mass media, on public transportation and in all public places. It also bans any form of tobacco advertising aimed at minors.

The government has also been adamant about supporting the tobacco industry by planning to double cigarette production to 524.2 billion cigarettes a year by 2020, the Industry Ministry’s 2015 tobacco industry roadmap states.

“If we see the roadmap, we can just imagine our little children being told to smoke,” the Health Ministry’s director of non- communicable diseases, Lily Sulistyowati, said.

Hans Nicholas Jong is a Jakarta Post reporter.

Mapped: The countries that smoke the most cigarettes

To mark World No-Tobacco Day, we’ve mapped the world according to cigarette consumption.

Those countries shown in darker colours smoke the most; those in lighter ones the least.


As with alcohol consumption, Eastern European countries dominate. Montenegro, where 4,124.53 cigarettes are smoked per adult per year, according to 2014 figures from the World Health Organisation (WHO), is the top of the pile, while Belarus, Macedonia, Russia, Slovenia and Bosnia also make the top 10.

The 20 countries that smoke the most

  1. Montenegro
  2. Belarus
  3. Lebanon
  4. Macedonia
  5. Russia
  6. Slovenia
  7. Belgium
  8. Luxembourg
  9. China
  10. Bosnia and Herzegovina
  11. Czech Republic
  12. Kazakhstan
  13. Azerbaijan
  14. Greece
  15. South Korea
  16. Austria
  17. Jordan
  18. Ukraine
  19. Estonia
  20. Hungary

Lebanon and China are the most tobacco-dependent non-European countries. Few regular visitors to Greece will be surprised to see it at 14th. Other popular summer holiday destinations not far from the smokers’ summit include Croatia, Turkey and Italy.

Britons, conversely, consume far fewer cigarettes – just 827.48 per adult per year – placing it 73rd on the list. The US is slightly higher, at 58th.

Residents of Guinea should be proud of the fact that they smoke the least of all those countries to feature in the WHO’s list. The Pacific nations also fare well, with the Solomon Islands, Kiribati and Vanuatu among the 10 most tobacco-free countries.

There is also a clear relationship between wealth and tobacco consumption. Many of the world’s poorest countries can be found in the lower reaches of the rankings. Those with no data appear in grey on the map above.

The 20 countries that smoke the least

  1. Guinea
  2. Soloman Islands
  3. Kiribati
  4. Rwanda
  5. Samoa
  6. Democratic Republic of the Congo
  7. Vanuatu
  8. Suriname
  9. Malawi
  10. Tonga
  11. Mozambique
  12. Nepal
  13. Afghanistan
  14. Lesotho
  15. Trinidad and Tobago
  16. Burundi
  17. Tanzania
  18. Liberia
  19. Niger
  20. Sao Tome and Principe

Top 10 facts about tobacco

TODAY is World No Tobacco Day, which has been celebrated on May 31 every year since it was created by the World Health Organisation in 1988.

  1. The word tobacco comes from a Caribbean language but it is unclear whether it meant a tube of tobacco leaves or the pipe they were smoked in.
  2. The island of Tobago was once called tavaco or tobaco, possibly for its cigar-like shape.
  3. The annual tax revenue from tobacco in the UK is more than £12 billion
  4. Around a third of the world’s adult population are smokers.
  5. It was been calculated that every cigarette a person smokes reduces their expected life span by 11 minutes.
  6. Worldwide, 15 billion cigarettes are smoked every day.
  7. In 1604 King James VI wrote A Counterblaste To Tobacco, attacking the practice of smoking.
  8. He described it as a “Custome lothsome to the eye, hatefull to the Nose, harmefull to the braine, dangerous to the Lungs.”
  9. In 1665 pipe-smoking was compulsory among pupils at Eton as a defence against the plague.
  10. Rodrigo de Jerez, a crewman of Columbus, was the first known European smoker. He was thrown in jail for it as exhaling smoke was seen as satanic.

Tobacco Use in the USA

Submitted by Julie Russell, RN Tobacco Prevention Specialist Carter, Fallon, & Powder River County

• High school students who are current (past month) smokers: 15.7 percent (boys: 16.4 percent, girls: 15.0 percent); over 2.6 million
• High school males who currently use smokeless tobacco: 14.7 percent (girls: 2.9 percent)
• Kids (under 18) who try smoking for the first time each day: 2,500+
• Kids (under 18) who become new regular, daily smokers each day: 580
• Kids (3-11) exposed to secondhand smoke: 40.6 percent (Black: 67.9 percent White: 37.2 percent)
• Packs of cigarettes consumed by kids each year: approx. 540 million (nearly $1.2 billion per year in sales revenue)
• Adults in the USA who are current smokers: 16.8 percent (men: 18.8 percent, women: 14.8 percent); approx. 40 million
• Adults in the USA who smoke daily: 12.9 percent Deaths & Disease in the USA from Tobacco Use
• People who die each year from cigarette smoking and exposure to secondhand smoke: approx. 480,000+
• Kids under 18 alive today who will ultimately die from smoking (unless smoking rates decline): 5.6 million
• People in the USA who currently suffer from smoking-caused illness: 16 million+ Smoking kills more people than alcohol, AIDS, car accidents, illegal drugs, murders, and suicides combined, with thousands more dying from spit tobacco use. Of all the kids who become new smokers each year, almost a third will ultimately die from it. In addition, smokers lose a decade of life because of their smoking. For every person who dies from smoking, at least 30 more are suffering from serious smoking-caused disease and disability. Tobacco-Related Monetary Costs in the USA
• Total annual public and private health care expenditures caused by smoking: approx. $170 billion – annual federal and state government smoking-caused Medicaid payments: $39.6 billion (Federal share: $22.5 billion per year. States’ share: $17.1 billion) – Federal government smoking-caused Medicare expenditures each year: $45.0 billion – Other federal government tobacco-caused health care costs (e.g. through VA health care): $23.8 billion
• Annual health care expenditures solely from secondhand smoke exposure: $6.03 billion. Not included above are costs from smokeless or spit tobacco use or pipe/cigar smoking.
• Productivity losses caused by smoking each year: $151 billion (only includes costs from productive work lives shortened by smoking-caused death. Not included: costs from smoking-caused disability during work lives, smoking-caused sick days, or smoking-caused productivity declines when on the job.) Other non-healthcare costs from tobacco use include residential and commercial property losses from smoking -caused fires, tobacco related cleaning and maintenance, and expenditures through Social Security Survivors Insurance for kids who have lost at least one parent from a smoking-caused death.
• Taxpayers yearly fed/state tax burden from smoking-caused government spending: US$960 per household
• Smoking-caused health costs and productivity losses per pack sold in USA (low estimate):US $19.16 per pack
• Average retail price per pack in the USA (including sales tax): US$5.96 Tobacco Industry Advertising & Political Influence
• Annual tobacco industry spending on marketing its products nationwide: US$9.5 billion ($25+ million each day) Research studies have found that kids are three times as sensitive to tobacco advertising than adults and are more likely to be influenced to smoke by cigarette marketing than by peer pressure; and that a third of underage experimentation with smoking is attributable to tobacco company advertising and promotion.
• Tobacco company PAC contributions to federal candidates, 2014 election cycle: More than US$1.8 million
• Tobacco industry expenditures lobbying Congress in 2014: US$22.0 million.

Youth and Tobacco Use

If smoking continues at the current rate among youth in this country, 5.6 million of today’s Americans younger than 18 will die early from a smoking-related illness. That’s about 1 of every 13 Americans aged 17 years or younger alive today.1


Preventing tobacco use among youth is critical to ending the tobacco epidemic in the United States.

  • Tobacco use is started and established primarily during adolescence.2,3
    • Nearly 9 out of 10 cigarette smokers first tried smoking by age 18, and 99% first tried smoking by age 26.1,3
    • Each day in the United States, more than 3,200 youth aged 18 years or younger smoke their first cigarette, and an additional 2,100 youth and young adults become daily cigarette smokers.3
  • Flavorings in tobacco products can make them more appealing to youth.4
    • In 2014, 73% of high school students and 56% of middle school students who used tobacco products in the past 30 days reported using a flavored tobacco product during that time.

Estimates of Current Tobacco Use Among Youth


Cigarette smoking has declined among U.S. youth in recent years, but the use of some other tobacco products has increased.5


  • From 2011 to 2015, current cigarette smoking declined among middle and high school students.5,6
    • About 2 of every 100 middle school students (2.3%) reported in 2015 that they smoked cigarettes in the past 30 days—a decrease from 4.3% in 2011.
    • About 9 of every 100 high school students (9.3%) reported in 2015 that they smoked cigarettes in the past 30 days—a decrease from 15.8% in 2011.

Electronic cigarettes

  • Current use of electronic cigarettes increased among middle and high school students from 2011 to 2015.5,6
    • About 5 of every 100 middle school students (5.3%) reported in 2015 that they used electronic cigarettes in the past 30 days—an increase from 0.6% in 2011.
    • 16 of every 100 high school students (16.0%) reported in 2015 that they used electronic cigarettes in the past 30 days—an increase from 1.5% in 2011.


  • From 2011 to 2015, current use of hookahs increased among middle and high school students.5,6
    • 2 of every 100 middle school students (2.0%) reported in 2015 that they had used hookah in the past 30 days—an increase from 1.0% in 2011.
    • About 7 of every 100 high school students (7.2%) reported in 2015 that they had used hookah in the past 30 days—an increase from 4.1% in 2011.

Smokeless Tobacco

  • In 20155:
    • Nearly 2 of every 100 middle school students (1.8%) reported current use of smokeless tobacco.
    • 6 of every 100 high school students (6.0%) reported current use of smokeless tobacco.

All Tobacco Product Use

  • In 2015, about 7 of every 100 middle school students (7.4%) and about 25 of every 100 high school students (25.3%) used some type of tobacco product.5
  • In 2013, nearly 18 of every 100 middle school students (17.7%) and nearly half (46.0%) of high school students said they had ever tried a tobacco product.7

Use of multiple tobacco products is prevalent among youth.3

  • In 2015, about 3 of every 100 middle school students (3.3%) and 13 of every 100 high school students (13.0%) reported use of two or more tobacco products in the past 30 days.5
  • In 2013, more than 31 of every 100 high school students (31.4%) said they had ever tried two or more tobacco products.7

Youth who use multiple tobacco products are at higher risk for developing nicotine dependence and might be more likely to continue using tobacco into adulthood.7

“Current use” is determined by respondents indicating that they have used a tobacco product on at least 1 day during the past 30 days.

Tobacco product types include cigarettes, cigars, hookahs, snus, smokeless tobacco, pipes, bidis, dissolvable tobacco, and electronic cigarettes.

“Use” is determined by respondents indicating that they have used a tobacco product on at least 1 day during the past 30 days. †"Any tobacco product" includes cigarettes, cigars, smokeless tobacco (including chewing tobacco, snuff, dip, snus, and dissolvable tobacco), tobacco pipes, bidis, hookah, and electronic cigarettes. §Where percentages are missing, sample sizes were less than 50 and thus considered unreliable.

“Use” is determined by respondents indicating that they have used a tobacco product on at least 1 day during the past 30 days.
†”Any tobacco product” includes cigarettes, cigars, smokeless tobacco (including chewing tobacco, snuff, dip, snus, and dissolvable tobacco), tobacco pipes, bidis, hookah, and electronic cigarettes.
§Where percentages are missing, sample sizes were less than 50 and thus considered unreliable.

Factors Associated With Youth Tobacco Use

Factors associated with youth tobacco use include the following:

  • Social and physical environments;2,8
    • The way mass media show tobacco use as a normal activity can promote smoking among young people.
    • Youth are more likely to use tobacco if they see that tobacco use is acceptable or normal among their peers.
    • High school athletes are more likely to use smokeless tobacco than their peers who are non-athletes.9
    • Parental smoking may promote smoking among young people.
  • Biological and genetic factors2
    • There is evidence that youth may be sensitive to nicotine and that teens can feel dependent on nicotine sooner than adults.
    • Genetic factors may make quitting smoking more difficult for young people.
    • A mother’s smoking during pregnancy may increase the likelihood that her offspring will become regular smokers.
  • Mental health: There is a strong relationship between youth smoking and depression, anxiety, and stress.2
  • Personal perceptions: Expectations of positive outcomes from smoking, such as coping with stress and controlling weight, are related to youth tobacco use.2
  • Other influences that affect youth tobacco use include:2,8
    • Lower socioeconomic status, including lower income or education
    • Lack of skills to resist influences to tobacco use
    • Lack of support or involvement from parents
    • Accessibility, availability, and price of tobacco products
    • Low levels of academic achievement
    • Low self-image or self-esteem
    • Exposure to tobacco advertising

Reducing Youth Tobacco Use

National, state, and local program activities have been shown to reduce and prevent youth tobacco use when implemented together. They include the following:

  • Higher costs for tobacco products (for example, through increased taxes)2,10,11
  • Prohibiting smoking in indoor areas of worksites and public places2,10,11
  • Raising the minimum age of sale for tobacco products to 21 years, which has recently emerged as a potential strategy for reducing youth tobacco use11
  • TV and radio commercials, posters, and other media messages targeted toward youth to counter tobacco product advertisements2,10
  • Community programs and school and college policies and interventions that encourage tobacco-free environments and lifestyles2,10
  • Community programs that reduce tobacco advertising, promotions, and availability of tobacco products2,10

Some social and environmental factors have been found to be related to lower smoking levels among youth. Among these are:2

  • Religious participation
  • Racial/ethnic pride and strong racial identity
  • Higher academic achievement and aspirations

Continued efforts are needed to prevent and reduce the use of all forms of tobacco use among youth.


  1. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014 [accessed 2016 Apr 14].
  2. U.S. Department of Health and Human Services. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Office on Smoking and Health, 1994 [accessed 2016 Apr 14].
  3. U.S. Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012 [accessed 2016 Apr 14].
  4. Centers for Disease Control and Prevention. Flavored Tobacco Product Use Among Middle and High School Students—United States, 2014. Morbidity and Mortality Weekly Report, 2015;64(38):1066–70 [accessed 2016 Apr 14].
  5. Centers for Disease Control and Prevention. Tobacco Use Among Middle and High School Students—United States, 2011–2015. Morbidity and Mortality Weekly Report, 2016;65(14):361–7 [accessed 2016 Apr 14].
  6. Centers for Disease Control and Prevention. Tobacco Product Use Among Middle and High School Students—United States, 2011 and 2012. Morbidity and Mortality Weekly Report, 2013;62(45):893–7 [accessed 2016 Apr 14].
  7. Centers for Disease Control and Prevention. Tobacco Use Among Middle and High School Students—United States, 2013. Morbidity and Mortality Weekly Report, 2014;63(45):1021–6 [accessed 2016 Apr 14].
  8. U.S. Department of Health and Human Services. Reducing Tobacco Use: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000 [accessed 2016 Apr 14].
  9. Centers for Disease Control and Prevention. Combustible and Smokeless Tobacco Use Among High School Athletes—United States, 2001–2013. Morbidity and Mortality Weekly Report, 2015;64(34):935–9 [accessed 2016 Apr 14].
  10. Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs—2014. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014 [accessed 2016 Apr 14].
  11. King BA, Jama AO, Marynak KL, Promoff GR. Attitudes Toward Raising the Minimum Age of Sale for Tobacco Among U.S. Adults. American Journal of Preventive Medicine 2015. E-pub ahead of print: DOI: [accessed 2016 Apr 14].


Electronic cigarette marketing tactics in mainland China

China produces 41% and consumes >38% of the world’s cigarettes.1 It is also a global production and export centre of the electronic cigarette (e-cigarette) industry. Around 95% of the world’s e-cigarettes are manufactured in China, mainly in the southeastern metropolis of Shenzhen,2 but the market share of e-cigarettes is tiny within the country.2 According to the most recent data of the International Tobacco Control Survey, only 2% of adult current or former smokers in China had ever used e-cigarettes in 2009.3 However, e-cigarette use has become increasingly popular, particularly among young people.4 The large smoker population and the hardening tobacco control measures (many cities have enacted local smoke-free laws,5 and a nationwide smoke-free law has been drafted6) create a huge potential for the e-cigarette market in the country…

Is America’ First Tobacco-Free Generation Just Around The Corner?

Globally, for the last 50 years we have known that people who smoke cigarettes are more likely to develop and die from certain diseases than people who don’t smoke. In America alone, more than 20 million people have died because of smoking since 1964. However, 2.5 million were also nonsmokers who died, because they inhaled secondhand smoke, which is air polluted by other people’s cigarette smoke. Sadly, it is not only adults who are at risk, as about half of all the children between ages three and 18 years in the U.S. are exposed to cigarette smoke regularly, either at home or in places such as restaurants that still allow smoking.

For decades, the tobacco industry has been encouraging us to smoke through images that make smoking appealing in films and on television. As a result of this marketing by the tobacco industry, more than 3,200 children younger than 18 years old smoke their first cigarette every day in America. Nearly nine out of 10 smokers start before the age of 18, and 98 percent start smoking by the age of 26. Every adult who dies early because of smoking is replaced by two new, young smokers; if current risks hold, one of the two also will die early from smoking.

Many smokers choose to smoke in spite knowing the health risks because they are addicted to the nicotine in the tobacco. It only takes ten seconds for the nicotine from one puff of smoke to reach the brain and this rapid delivery of nicotine from the lungs to the brain is one of the reasons that cigarettes are so addictive. The nicotine causes cells in the brain to release dopamine; one of the main effects of dopamine released in the brain is to create a heightened sense of alertness and contentment. Over time, the brain cells of smokers are changed to expect the regular bursts of extra dopamine that result from smoking. When a smoker tries to quit, these brain changes cause strong cravings for more nicotine.

So, what will it take to be the first tobacco-free generation in America? Is it at all possible? Attempting to create this change is CVS Health, which has launched Be The First, a $50 million, five-year commitment, funded through the company and the CVS Health Foundation, to help deliver the nation’s first tobacco-free generation through education, advocacy, tobacco control and healthy behavior programming. The CVS Health Foundation has partnered with Scholastic, the global children’s publishing, education and media company, to introduce a school-based tobacco-prevention education program that teaches children about the health consequences of tobacco use and why it’s important to never start.

20 myths about smoking that will not die

Originally published as two columns on The Conversation, we bring you the definitive list of 20 myths about smoking that will not die by Simon Chapman, University of Sydney

Across forty years I’ve come to recognise many factoid-driven myths about smoking that just won’t die. If I asked for a dollar each time I had to refute these statements, I’d have accumulated a small fortune.

Their persistence owes much to their being a vehicle for those who utter them to express unvoiced but clear sub-texts that reflect deeply held beliefs about women, the disadvantaged, mental illness, government health campaigns and the “natural”.

Let’s drive a stake through the heart of ten of the most common myths.

1. Women and girls smoke more than men and boys

Women have never smoked more than men. Occasionally, a survey will show one age band where it’s the other way around, but from the earliest mass uptake of smoking in the first decades of last century, men streaked out way ahead of women.

In 1945 in Australia, 72% of men and 26% of women smoked. By 1976, men had fallen to 43% and women had risen to 33%.

As a result, men’s tobacco-caused death rates have always been much higher than those of women. Women’s lung cancer rates, for example, seem unlikely to reach even half the peak rates that we saw among men in the 1970s.

Currently in Australia, 15% of men and 12% of women smoke daily.

But what about all the “young girls” you can see smoking, I’m always being told. In 2014, 13% of 17-year-old male high school students and 11% of females smoked. In two younger age bands, girls smoked more (by a single percentage point).

Those who keep on insisting girls smoke more are probably just letting their sexist outrage show about noticing girls’ smoking than their ignorance about the data.

2. Quit campaigns don’t work on low socioeconomic smokers

In Australia, 11% of those in the highest quintile of economic advantage smoke, compared with 27.6% in the lowest quintile. More than double.

So does this mean that our quit campaigns “don’t work” on the least well-off?

Smoking prevalence data reflect two things: the proportion of people who ever smoked, and the proportion who quit.

If we look at the most disadvantaged group, we find that a far higher proportion take up smoking than in their more well-to-do counterparts. Only 39.5% have never smoked compared with 50.4% of the most advantaged – see table 9.2.6).

When it comes to quitting, 46% of the most disadvantaged have quit compared to 66% of the least disadvantaged (see table 9.2.9).

There is a higher percentage of the disadvantaged who smoke mainly because more take it up, not because disadvantaged smokers can’t or won’t quit. With 27.6% of the most disadvantaged smoking today, the good news is that nearly three-quarters don’t. Smoking and disadvantage are hardly inseparable.

3. Scare campaigns ‘don’t work’

Countless studies have asked ex-smokers why they stopped and current smokers about why they are trying to stop. I have never seen such a study when there was not daylight between the first reason cited (worry about health consequences) and the second most nominated reason (usually cost).

For example, this national US study covering 13 years showed “concern for your own current or future health” was nominated by 91.6% of ex-smokers as the main reason they quit, compared with 58.7% naming expense and 55.7% being concerned about the impact of their smoking on others.

If information and warnings about the dire consequences of smoking “don’t work”, then from where do all these ex-smokers ever get these top-of-mind concerns? They don’t pop into their heads by magic. They encounter them via anti-smoking campaigns, pack warnings, news stories about research and personal experiences with dying family and friends. The scare campaigns work.

4. Roll-your-own tobacco is more ‘natural’ than factory made

People who smoke rollies often look you in the eye and tell you that factory made cigarettes are full of chemical additives, while roll-your-own tobacco is “natural” – it’s just tobacco. The reasoning here that we are supposed to understand is that it’s these chemicals that are the problem, while the tobacco, being “natural”, is somehow OK.

This myth was first turned very unceremoniously on its head when New Zealand authorities ordered the tobacco companies to provide them with data on the total weight of additives in factory made cigarettes, roll-your-own and pipe tobacco.

For example, data from 1991 supplied by WD & HO Wills showed that in 879,219kg of cigarettes, there was 1,803kg of additives (0.2%). While in 366,036kg of roll-your-own tobacco, there was 82,456kg of additives (22.5%)!

Roll-your-own tobacco is pickled in flavouring and humectant chemicals, the latter being used to keep the tobacco from drying out when smokers expose the tobacco to the air 20 or more times a day when they remove tobacco to roll up a cigarette.

5. Nearly all people with schizophrenia smoke

It’s true that people with mental health problems are much more likely to smoke than those without diagnosed mental health conditions. A meta-analysis of 42 studies on tobacco smoking by those with schizophrenia found an average 62% smoking prevalence (range 14%-88%). But guess which study in these 42 gets cited and quoted far more than any of the others?

If you said the one reporting 88% smoking prevalence you’d be correct. This small 1986 US study of just 277 outpatients with schizophrenia has today been cited a remarkable 1,135 times. With colleagues, I investigated this flagrant example of citation bias (where startling but atypical results stand out in literature searches and get high citations – “wow! This one’s got a high number, let’s quote that one!”).

By googling “How many schizophrenics smoke”, we showed how this percolates into the community via media reports where figures are rounded up in statements such as, “As many as 90% of schizophrenic patients smoke.”

Endlessly repeating that “90%” of those with schizophrenia smoke does these people a real disservice. We would not tolerate such inaccuracy about any other group.

6. Everyone knows the risks of smoking

Knowledge about the risks of smoking can exist at four levels:

Level 1: having heard that smoking increases health risks.
Level 2: being aware that specific diseases are caused by smoking.
Level 3: accurately appreciating the meaning, severity, and probabilities of developing tobacco related diseases.
Level 4: personally accepting that the risks inherent in levels 1–3 apply to one’s own risk of contracting such diseases.

Level 1 knowledge is very high, but as you move up the levels, knowledge and understanding greatly diminish. Very few people, for example, are likely to know that two in three long term smokers will die of a smoking caused disease, nor the average number of years that smokers lose off normal life expectancy.

7. You can reduce the health risks of smoking by just cutting down

It’s true that if you smoke five cigarettes a day rather than 20, your lifetime risk of early death is less (although check the risks for one to four cigarettes a day here).

But trying to “reverse engineer” the risk by just cutting down rather than quitting has been shown in at least four large cohort studies such as this one to confer no harm reduction.

If you want to reduce risk, quitting altogether should be your goal.

8. Air pollution is the real cause of lung cancer

Air pollution is unequivocally a major health risk. By “pollution”, those who make this argument don’t mean natural particulate matter such as pollen and soil dusts, they mean nasty industrial and vehicle pollution.

The most polluted areas of Australia are cities where pollution from industry and motor vehicle emissions are most concentrated. Remote regions of the country are the least polluted, so if we wanted to consider the relative contributions of air pollution and smoking to smoking-caused diseases, an obvious question to ask would be “does the incidence of lung cancer differ between heavily polluted cities and very unpolluted remote areas?”

Yes it does. Lung cancer incidence is highest in Australia in (wait for this …) in the least polluted very remote regions of the country, where smoking prevalence happens also to be highest.

9. Smokers should not try to quit without professional help or drugs

If you ask 100 ex-smokers how they quit, between two-thirds and three-quarters will tell you they quit unaided: on their final successful quit attempt, they did not use nicotine replacement therapy, prescribed drugs, or go to some dedicated smoking cessation clinic or experience the laying on of hands from some alternative medicine therapist. They quit unaided.

So if you ask the question: “What method is used by most successful quitters when they quit?” The answer is cold turkey.

Fine print on this English National Health Service poster states a bald-faced lie by saying that “There are some people who can go cold turkey and stop. But there aren’t many of them.” In the years before nicotine-replacement threapy and other drugs were available, many millions – including heavy smokers – quit smoking without any assistance. That’s a message that the pharmaceutical industry was rather not megaphoned.

10. Many smokers live into very old age: so it can’t be that harmful

In just the way that five out of six participants in a round of deadly Russian roulette might proclaim that putting a loaded gun to their head and pulling the trigger caused no harm, those who use this argument are just ignorant of risks and probability.

Many probably buy lottery tickets with the same deep knowing that they have a good chance of winning.

Ten more myths about smoking that will not die

There’s plainly a big appetite for smoking myth busting, so here are 10 more.

1. Today’s smokers are all hard core, addicted smokers who can’t or won’t give up

This claim is the essence of what is known as the “hardening hypothesis”: the idea that decades of effort to motivate smokers to quit has seen all the low-hanging fruit fall from the tree, leaving only deeply addicted, heavy smokers today.

The key index of addicted smoking is the number of cigarettes smoked per day. This creates a small problem for the hardening hypothesis: in nations and states where smoking has reduced most, the average number of cigarettes smoked daily by continuing smokers has gone down, not up. This is exactly the opposite of what the hardening hypothesis would predict if remaining smokers were mostly hard core.

2. Smoking is pleasurable

Repeated studies have found that around 90% of smokers regret having started, and some 40% make an attempt to quit each year. There’s no other product with even a fraction of such customer disloyalty.

But I’m always amused at some die-hard smokers’ efforts explain that they smoke for pleasure and so efforts to persuade them to stop are essentially just anti-hedonistic tirades. Many studies have documented that the “pleasure” of smoking centres around the relief smokers get when they have not smoked for a while. The next nicotine hit takes away the discomfort and craving they have been experiencing.

This argument is a bit like saying that being beaten up every day is something you want to continue with, because hey, it feels so good when the beating stops for a while.

3. Light and mild cigarettes deliver far less tar and nicotine to the smoker than standard varieties

Several nations have outlawed cigarette descriptors such as “light” and “mild” because of evidence that such products do not deliver lower amounts of tar and nicotine to smokers, and so are deceptive.

The allegedly lower yields from cigarettes labelled this way resulted from a massive consumer fraud.

Cigarette manufacturers obtained these low readings by laboratory smoking machine protocols which took a standardized number of puffs, at a standardized puff velocity. The smoke inhaled by the machine was then collected in glass “lungs” behind the machine and the tar and nicotine weighed to give the readings per cigarette.

But the companies didn’t tell smokers two things. So-called light or mild cigarettes had tiny, near-invisible pin-prick perforations just on the filter (see picture). These holes are not covered by the “lips” or “fingers” of the laboratory smoking machine, allowing extra air to be inhaled and thus diluting the dose of tar and nicotine being collected.

But when smokers use these products, two things happen. Their lips and fingers partially occlude the tiny ventilation holes, thus allowing more smoke to be inhaled. Smokers unconsciously “titrate” their smoking to obtain the dose of nicotine that their brain’s addiction centres demand: they can take more puffs, inhale more deeply, leave shorter butt lengths or smoke more cigarettes.

Today, where use of these descriptors has been stopped, the consumer deception continues with the companies using pack colours to loudly hint to smokers about which varieties are “safer”.

4. Filters on cigarettes remove most of the nasty stuff from cigarettes

We’ve all seen the brown stain in a discarded cigarette butt. But what few have seen is how much of that same muck enters the lungs and how much stays there.

This utterly compelling video demonstration shows how ineffective filters are in removing this deadly sludge. A smoker demonstrates holding the smoke in his mouth and then exhales it through a tissue paper, leaving a tell-tale brown stain. He then inhales a drag deep into his lungs, and exhales it into a tissue. The residue is still there, but in a much reduced amount. So where has the remainder gone? It’s still in the lungs!

5. Governments don’t want smoking to fall because they are addicted to tobacco tax and don’t want to kill a goose that lays golden eggs

This is perhaps the silliest and most fiscally illiterate argument we hear about smoking. If governments really want to maximise smoking and tax receipts, they are doing a shockingly bad job of it. Smoking in Australia has fallen almost continuously since the early 1960s. In five of the 11 years to 2011, the Australian government received less tobacco tax receipts than it did the year before (see Table 13.6.6).

Plainly, as smoking continues to decline, diminishing tax returns will occur, although this will be cushioned by the rising population which will include some smokers.

In the meantime, tobacco tax is a win-win for governments and the community. It reduces smoking like nothing else, and it provides substantial transfer of funds from smokers to government for public expenditure.

Those of us who don’t smoke do not squirrel away what we would have otherwise spent on smoking in a jam jar under the bed. We spend it on other goods and services, benefiting the economy too.

6. Most smokers die from smoking caused diseases late in life, and we’ve all got to die from something

Smoking increases the risk of many different diseases, and collectively these take about ten years off normal life expectancy from those who get them.

Smoking is by far the greatest risk factor for lung cancer. In Australia, the average age of death for people with lung cancer is 71.4 (see Table 4.2), while life expectancy is currently 80.1 for men and 84.3 for women.

This means that, on average, men diagnosed with lung cancer lose 8.7 years and women 12.9 years (mean 10.8 years). Of course, some lose many more (Beatle George Harrison died at just 58, Nat King Cole at 45).

If a 20-a-day smoker starts at 17 and dies at 71, 54 years of smoking would see 394,470 cigarettes smoked. At ten puffs per cigarette, that’s some 3.94 million point-blank lung bastings.

It takes about six minutes to smoke a cigarette. So at 20 a day, smokers smoke for two hours each day. Across 54 years, that’s a cumulative 1,644 days of smoking (4.5 years of continual smoking if you put it all together).

So by losing ten years off life expectancy, each cigarette smoked takes about 2.2 times the time it takes to smoke it off the life expectancy that might otherwise have been enjoyed.

7. Smokers cost the health system far more than the government receives from tobacco tax

In June 2015, a senior staff member of Australian libertarian Senator David Leyonhjelm, Helen Dale tweeted:

In Australia, a now old report looking at 2004/05 data estimated the gross health care costs attributable to smoking “before adjustment for savings due to premature death” were $A1.836 billion. In that financial year, the government received $A7,816.35 billion in customs and excise duty and GST on tobacco.

Someone who thought that the fiscal ledger was all that mattered in good government might conclude from this that smokers easily pay their way and perhaps we should even encourage smoking as a citizen’s patriotic duty.

With smokers being considerate enough to die early, these noble citizens lay down their lives early and thus contribute “savings due to premature death” like failing to draw a state pension or needing aged care services late in life.
Philip Morris notoriously gave this advice to the new Czech government in 1999.

Other assessments, though, might well point to the values inherent in such assessments. History’s worst regimes have often seen economically non-productive people as human detritus deserving death. Primo Levi’s unforgettable witnessing of this mentality in Auschwitz comes to mind.

8. Big Tobacco is starting to invade low-income nations, now that smoking is on the wane in the wealthiest nations

Sorry, but US and British manufacturers have been aggressively marketing cigarettes in places such as China since the early years of last century. These collectable posters show many featuring Chinese women.

The large populations, the often lax tobacco-control policies and the higher corruption indexes of many low- and middle-income nations makes many of these nirvanas for Big Tobacco.

There are fewer more nauseating experiences than reading the corporate social responsibility reports of tobacco transnationals and then seeing how they operate in smokers’ paradises such as Indonesia. This documentary says it all.

9. Millions of cigarette butts on the world’s beaches leach lots of toxic chemicals into oceans

Cigarette butts are the most discarded items in all litter. Every year uncounted millions if not billions are washed down gutters in storm water and find their way into rivers, harbours and oceans. Cigarette filters and butts contain toxic residue and experiments have shown that placing laboratory fish in containers for 48 hours with leachate extracted from used cigarette butts, 50% of the fish die. From this, we sometimes hear people exclaim that cigarette butts are not just unsightly, but they “poison the oceans”.

But a confined laboratory container does not remotely mirror real life exposures in oceans or rivers. There are some 1,338,000,000 cubic kilometers of water in the world oceans, so the contribution of cigarette butts to the toxification of all this could only excite a homeopath.

If we want to reduce tobacco litter, we need not wander into such dubious justifications. The best way by far is to keep reducing smoking. Industry attempts at portraying themselves as corporately responsible by running dinky little clean-up campaigns or distributing personal butt disposal canisters avoids their efforts to keep as many smoking as possible.

10. Tobacco companies care deeply about their best customers dying early

Naturally, all businesses would rather their customers lived as long as possible so that the cash registers can keep ringing out long and loud. Tobacco companies wish their products didn’t kill so many, but worship the god nicotine for its iron grip on so many.

Visit any tobacco transnational’s website and you will find lots of earnest and caring talk about the companies’ dedication to doing all they can to reduce the terrible harm caused by their products. All the major companies have now invested heavily in electronic cigarettes, so isn’t this a sign that they taking harm reduction seriously?

It might be if the same companies were showing any sign of taking their feet off the turbo-drive accelerator of opposing effective tobacco control policies. But they are doing nothing of the sort. All continue to aggressively attack and delay any policy like tax hikes, graphic health warnings, plain packaging and advertising bans wherever in the world these are planned for introduction.

For all their unctuous hand-wringing about their mission to reduce harm, they are all utterly determined to keep as many smoking as possible. Big Tobacco’s business plan is not smoking or ecigarettes. It’s smoking and ecigarettes. Smoke when you are able to, vape when you can’t. It’s called dual use and some 70% of vapers are doing just that. The tragedy now playing out in some nations is that too many gormless tobacco control experts are blind to this big picture.

Simon Chapman, Emeritus Professor in Public Health, University of Sydney

When tobacco prices go up, consumption goes down

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Hong Kong Smoking Prevalence

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