ATHRA, a small Australian lobby group for e-cigarettes with a Twitter following today of all of 494 (including many vaping activists from overseas), often argues that smoking prevalence in Australia is lagging behind the US and the UK. Its website states “Australia’s National Health Survey confirms that smoking rates have plateaued in Australia. According to the national survey this month, 15.2% of Australians adults smoked in 2017-18 compared to 16% three years ago.”

“Current smoking” to the Australian Bureau of Statistics means daily smoking plus “other” which means “current smoker weekly (at least once a week, but not daily) and current smoker less than weekly.” We now have 13.8% of adults smoking daily, and a further 1.4% less than daily.

And very critically, unlike in the USA and the UK, Australian data on “smoking” explicitly include use of other combustible tobacco products (see questions establishing “smoking” below). This means that Australia’s 2017-2018 15.2% smoking prevalence includes exclusive cigarette smokers, all cigarette smokers who also smoke other combustible tobacco products and any smokers who exclusively smoke any of the non-cigarette combustible products (eg: cigars, cigarillos, pipes, waterpipes, bidis).

ATHRA repeatedly asserts that the US and the UK, both awash with ecigarettes, have both galloped ahead of Australia in reducing smoking. A tweet from November 9, 2018 (below) shows  a graph they like to use.

US smoking prevalence: 14%  … or as high as 17.3%?

ATHRA’s graph above shows the US National Health Interview Survey (NHIS) “18+ smoking rate” being 14% for 2017. NIHAS defines “Current cigarette smokers [as] respondents who reported having smoked ≥100 cigarettes during their lifetime and were smoking every day or some days at the time of interview.”

But in fact, 14%  is the US prevalence for only cigarette smoking, not all smoking— see https://www.cdc.gov/nchs/nhis/SHS/tables.htm If we add all the other smoked tobacco products in widespread use in the USA (cigars, cigarillo, pipes, water pipes, hookahs, bidis) the prevalence of smokers who use any combusted tobacco product rises to 16.7% with an upper confidence internal boundary of 17.3% (see the table here).  Quite a way above Australia’s 15.2% rate.

More recent US data for the first half of 2018 show “the percentage of adults aged 18 and over who were current cigarette smokers was 13.8% (95% confidence interval = 13.08%-14.53%) which was not significantly different from the 2017 estimate of 13.9%.” So far, ATHRA has not issued any public statements about the fall in cigarette smoking stagnating in the US despite some 3% of adults vaping, but these can’t be far off. Surely?

The year before (2016), also in the midst of untrammelled ecigarette promotions, the prevalence of current cigarette smoking among US adults was 15.5%, a  slight but statistically nonsignificant rise from the 2015  figure of 15.1%.

Also, the 2016 NHIS US cigarette smoking prevalence estimate (15.1%) was a massive 24.5% lower than seen in the cigarette smoking prevalence figure (21%) for those aged 18+ in the 2015 National Survey on Drug Use and Health (NSDUH). With such different estimates, plainly, the real proportion is debatable.

A commentary in Addiction published in March 2017 commenting on another US survey noted “While it is possible that some proportion of non‐cigarette combustible tobacco use is concurrent with cigarette smoking, it is likely that overall combustible tobacco use prevalence for adults 18+ in the United States is higher than 15.2%, and somewhere in line or just below the 2013–14 National Adult Tobacco Survey (NATS) estimate that 18.4% of US adults aged 18+ were current users of any combustible tobacco product (defined by NATS as use every day or some days, with different thresholds of life‐time use by combustible tobacco product)”

UK

The UK government’s official smoking survey asks “do you smoke cigarettes at all nowadays? Please exclude electronic cigarettes”. In 2017, 15.1% of UK adults aged 18+ answered yes, but this figure also does not include people who smoke only non-cigarette combustible tobacco products such as cigars and pipe tobacco. So yes. 15.1% may be a cigarette paper below Australia’s 15.2% rate but it’s hardly a “man the lifeboats, the boat is sinking” difference that ATHRA and its spokespeople try to paint.

Latest adult prevalence data summary

• Australia: 15.2% (includes cigarette smokers plus all exclusive users of other combustible tobacco products)
• UK: 15.1% (cigarettes only: other exclusive combustible tobacco product users to be added)
• USA: 13.8% (cigarettes only: other exclusive combustible tobacco product users to be added)

And mostly down to ecigarettes?

ATHRA  argue that the widespread use of ecigarettes is a major factor explaining the falls in smoking prevalence in the UK and the USA. The graph below from the Smoking in England project transposes the dramatically increased use of ecigarettes in quit attempts with the slow decline in adult smoking prevalence in England.

No one could look at this graph and point to any clear relationship between the two.

By contrast, the graph below shows the relationship between cigarette costliness and smoking prevalence in the UK. It is very clear that as the real price of tobacco rose (and hence costliness increased) that smoking prevalence fell, in an almost complete inverse relationship.

Source: Smoking prevalence and Tobacco affordability index

Huge prevention effect of Australian tobacco control

Colin Mendelsohn from ATHRA has been beating the same “the wheels have fallen off falling smoking prevalence” drum since 2017. I criticised his statements at length here in August 2017.

What’s missing in his almost total focus on what’s happening with smoking prevalence, is that while Australia’s current decline in smoking prevalence status compares favourably to the US and UK, our data on youth smoking prevention are quite stunning. Only 1.9% of 15-17 year old Australians smoked in 2017-2018, down from 2.7% in 2014-2015 and 3.8% in 2011-2012. This is a 50% fall in the 7 years 2011-2018, during which time Australia introduced plain packs and a series of annual 12.5% tax increases from 2013-2018.

The proportion of adult Australians who have never smoked was 52.6% in 2014-15 and rose to 55.7% in 2017-18. These figures are the tobacco industry’s on-going nightmare, presaging it as a sunset industry which will wither and starve from lack of “replacement” customers as its current users quit or die.

In my August 2017 critique I highlighted several reasons why Mendelsohn’s claim at the time that there had been an increase in the number of smokers in Australia needed careful circumspection. I wrote:

“Mendelsohn appears to have arrived at a figure of 21 000 extra smokers by multiplying the percentage of daily smokers listed for each year in Table 3 of the AIHW report, with an estimate of population numbers of Australians 18 years and over in June 2013 and 2016 released by the Australian Bureau of Statistics in June 2017. These population estimates were published some months after the AIHW would have undertaken the analysis of smoking prevalence for 2016 and some years after it released its estimate of prevalence in 2013.

The estimate ignores the complexity of how survey results are weighted by population composition. It also ignores the fact that the prevalence figure is only an estimate, with margins of error. The AIHW’s table of relative standard errors and margins of error indicates that the prevalence of daily smoking among people aged 18 years and over in 2016 was somewhere between 12.2% and 13.4%. This means that the number of smokers in 2016 could have been anywhere between 2 293 000 and 2 512 000. A similar range applies to the figure for 2013. The calculation of an extra 21 000 smokers between 2013-2016 is therefore essentially meaningless.

Moreover, the Australian Bureau of Statistics population figures show that between 2013 and 2016, Australia’s population aged 18 years and over grew by 864 340 people as a result of births, deaths and immigration. Many immigrants in this number would be from nations where smoking rates are high, particularly among men.

The elephant in the room? Massive growth in never smokers from smoking prevention.

Media attention has focused on smokers. But applying the same calculation Dr Mendelsohn has done for current smokers to people in the rest of the population, one would conclude that there are more than 870 000 extra non-smokers in Australia in 2016 than there were in 2013 — more than 80 times the number of extra current smokers (and more than 40 times the number of extra daily smokers) that he is so concerned about.”

ATHRA has egg on its face with its apparently naïve understanding of what smoking prevalence data for the three countries actually mean.

Professor Robert West (a leading figure in tobacco cessation research, editor-in-chief of Addiction  and director of the large Smoking in England national study told the BBC in February 2016:

“[This widespread use of e-cigarettes] raises an interesting question for us:  If they were this game changer, if they were going to be – have this massive effect on everyone switching to e-cigarettes and stopping smoking we might have expected to see a bigger effect than we have seen so far which has actually been relatively small” [my emphasis]

and

“We know that most people who use e-cigarettes are continuing to smoke and when you ask them they’ll tell you that they’re mostly doing that to try to cut down the amount they smoke.  But we also know that if you look at how much they’re smoking it’s not really that much different from what they would have been doing if they weren’t using an e-cigarette.  So I think as far as using an e-cigarette to reduce your harm while continuing to smoke is concerned there really isn’t good evidence that it has any benefit.” [my emphasis]

Esther Han at the Sydney Morning Herald reported earlier this year here about funding received by ATHRA from two companies involved in the vaping industry and here about their receipt of $8000 from an organisation that received funding tobacco companies.

Fortunately, governments in Australia have heeded the evidence reviews from the CSIRO, the Therapeutic Goods Administration and the NHMRC, and the advice from the overwhelming proportion of public health and medical organisations (table below) to take a precautionary approach about many of the over-hyped claims being made for ecigarettes and the vast areas of research where the evidence remains non-existent or very limited.

 

With multi-party support, Australia remains in the very front line of global tobacco control with commitments like plain packaging, high taxation, retail display bans and smoke free policies. Australia’s smoking prevalence would look a lot better if governments had not fallen asleep at the wheel in one critical areas- failing to run evidence-based national media campaigns since 2012.

ATHRA’s public statements need to be scrutinized very, very carefully.

Tailpiece

After it was recently announced that Philip Morris/Altria is planning to invest in cannabis, ATHRA’s Colin Mendelsohn tweeted on Dec 8 that it was “surely a good thing if they make money” from this move. With 20.8% of US high school kids now currently vaping (at least once in the past 30 days)  compared to 3% of US adults, and the immense appeal of Juul involving its discreet properties (easily secreted, minimal clouding, memory stick lookalike), it is reasonable to ask what could possibly go wrong with PMI’s planned entry into the cannabis market. Vaping equipment is already being used to vape cannabis and other  drugs. Philip Morris of course would be horrified if children were to vape dope before sitting down in the classroom. It would just never happen, right?

[Updated 19 Mar, 2025]

I wrote my first book in 1983. It was a small manual of tactics for counteracting the tobacco industry’s promotional strategies, described by a tobacco industry snoop at the conference where I sold it to delegates as  “a rather paranoid and disturbing `contribution’ by an Australian called Simon Chapman”. I got a small grant from an international consumer organisation to print it and I took 300 copies to the 5^th World Conference on Smoking and Health in Canada where I sold copies for $5, recouping my excess baggage charge and adding a few first gold bricks to an authorship royalties’ pathway I planned to pave during the rest of my career. On the final night I spread all the bank notes over my hotel bed and dived into it, Scrooge McDuck style. I was on my way!

I followed this by convincing a small media studies publisher in London to publish a book from my PhD thesis in 1986. Great Expectorations: advertising and the tobacco industry. I never recall getting any royalties, but it got reviewed in the Times and the Guardian, with the Times even running an editorial. I got a lot of mail from readers. Long out of print, a US bookseller today hopes to extract $US169.73 for it from some discerning reader.

I then wrote a global atlas of tobacco control in the third world, as we called it then. The American Cancer Society paid for the printing and gave one to every delegate at the 7th world conference on tobacco control in Perth. This became the inspiration for subsequent international atlases of tobacco control published by the US Centers for Disease Control and later by Judith Mackay. I got no royalties for this one either and my hopes to put a deposit on an Aston Martin were looking ever fragile.

In 1994, I knew I was about to hit the big time when  British Medical Journal books published the first of two textbooks I wrote on the theory and practice of public health advocacy. This one, and the next (published by Wiley in 2007) saw annual royalty payments go into my bank. I never added them all up, but estimate that over the 24 years since I might have earned $12,000. Today my bank charges for the foreign deposits are usually as much as the annual royalties.

Two other books (one on gun control for Pluto Press and another on voluntary euthanasia) produced utterly desultory royalties, despite being on hot-button news issues. Like every author I’ve talked to, I spent many a weekend visiting bookshops sometimes looking in vain for these on the new releases display shelves.

These experiences left me convinced that writing non-fiction books was highly unlikely to earn me a living or even significant icing for my salary cake. But there are reputational benefits and indirect outcomes like conference invitations, consultancies and training opportunities that flow from publishing a book.

But well before thoughts of the untold riches heading their way, funnily enough every author hopes that their writing will be read. We polish, buff and manicure our babies through many revisions, all the time imagining the readers’ pleasure with the text. So when for my next five books I was given an opportunity to trade chimerical riches for gushing geysers of readers, I didn’t hesitate.

In 2009 I approached Sydney University Press with a book idea on the prostate cancer testing debate. My editor there, Agata Mrva-Montoya, set out several options: a commercial option with a paperback book where I would get the standard 10% royalty, a paid ebook option (with 25% royalty), or a hybrid open access option where there would be a paperback and ebook option available for sale and a  totally free (for readers) pdf download. SUP has some 50 titles in its catalogue available as open access.

I elected for the pay-for-print/free download option for this and all subsequent books I’ve done with SUP. They republished the gun control book which had seen around 1000 sold in paperback with Pluto. Links to all these books are here.

The table shows the total and average per day accesses since each book was published. (table updated 16 Oct, 2023)

Book, open access publication date	Total accesses (& per day)
Let sleeping dogs lie: what men should know before getting tested for prostate cancer. Oct 29, 2010	86,202 (16)
Over our dead bodies: Port Arthur and Australia’s fight for gun control. Jan 15, 2013	52,133 (12)
Removing the emperor’s clothes: Australia and plain  packaging. Nov 27, 2014	61,736 (16)
Smoke signals: selected writing. 28 Jul, 2017	14,222 (5)
Wind turbine syndrome: a communicated disease Dec 1, 2017	33,664 (13)
Quit smoking weapons of mass distraction Jul 25, 2022	8,607 (9)

These 256,564 accesses are very pleasing. I’m confident that a small fraction of that number would have been purchased if I’d gone for the pay-for-print option. My combined royalties to date for the print editions I’ve received for all of these books have been around $1000.

When I’ve recommended giving one’s books away online to authors who have gone down the sales-only route, I sometimes encounter a disdainful superiority in the remark “a curious mouse click on a pdf download button is not the same as someone actually reading a book”.

It’s certainly true that many people who open an online book don’t read it, or don’t read it fully.  But of course, the very same can be said about purchased books. How many books do we all have on our shelves that we bought with the intention reading them cover-to-cover but never got around to it?

I had a job throughout the years I wrote these books, so (thankfully) did not need to rely on income from publishing. Those who rely on writing for their living clearly cannot consider this route to readership.

For authors who do not need to rely on royalties, publishing open access is a good way to increase readership.