 I'd like to start by acknowledging the traditional custodians of the land on which we meet, and paying my respects to their elders past and present. I'd also like to thank the organisers for giving me this opportunity to talk to you. And I'd also like to acknowledge the dignitaries in the room, particularly the Vice-Chancellor, the Chief Medical Officer of Australia, and Senator Humphreys, and anyone else I've missed. But I'd also particularly like to thank all the members of the public who are here. And I'd particularly like to acknowledge my family, so my mum, my dad and my daughter. It's really nice to be able to have a gathering that brings together all of us. And I think that one of the awful things about smoking, but one of the great things is that it's a problem that unites us. Very few people are untouched in terms of themselves or their families by smoking. So I'm just going to start with a bit of background about smoking and health. And then I'm going to talk to you about the specific results we have from Australia. I'm going to talk about that in the context of international findings, and then talk about the implications. And I'm particularly pleased to have with us a couple of the people, Margie Thieson and Harry Crouse, I think. Who've been a really big part of the implementation and the development of ANU going smoke-free. And I know that there are a number of other people in the audience who've been involved in tobacco control policy. So I'm hoping that one of the big things about this talk is to bring together the research and the action. So Goethe says that thinking is easy and acting is difficult. And putting one's thoughts into action is the hardest thing in the world. So we in universities pride ourselves on the quality of our thinking. But what Goethe says is that actually taking those thoughts and putting them into action is incredibly difficult, particularly because it's sort of a messy real world out there. But I would add to that that if you do something that really works, that's really effective, well then you're really in trouble. And certainly in terms of tobacco control, we're really Australia's world leader. If you do something that's really effective, you'll find yourself not only in the highest court in the country, but possibly the highest court on the planet. So just bearing that in mind, when I started work on smoking and mortality, one of the major comments I had was why on earth would you do that? We know that smoking is bad for you. It says it on the packet. And I would absolutely agree that it is well established that smoking increases the risk of premature mortality. But one of the things that I hope you'll be convinced of by the time I finish my lecture is that magnitude matters. So it's not just a question of whether it's bad for you, but how bad it is for you actually matters. The other thing is that the risks related to smoking vary according to time and place. So they vary according to the stage in the tobacco epidemic that the country is. And they also vary according to location in terms of the nature of the epidemic in that particular place. So it's very, very important to have local evidence. And the other thing is that Australia, because of its really outstanding record in tobacco control, provides a unique context which can contribute to the international context. So one of the things that I think is really important is to remember that the forefront of knowledge differs from places from discipline to discipline. And even though it says it on the packet, there remains a forefront of knowledge on tobacco and on tobacco and mortality. So I'm going to talk now about global smoking. It's a massive problem and it's getting worse. And I think a lot of people think that because we've got reducing rates in Australia that somehow is a problem that is solved or it's old hat. But in fact we have around one billion daily smokers in the world today. And that's actually about a third of the men on the entire planet are current smokers and around 7% of women. On average they spoke 15 cigarettes a day. This is the map of the world in terms of smoking. The red areas represent areas of high smoking prevalence. This top part of the chart is men and this bottom part is women. So what you can see is a huge concentration, particularly across Asia. And if you look around Australia, our immediate region has a very distinct tobacco problem. The blue areas are low smoking. You can also see that there are large sex differentials between men and women in many of these countries. And you can also see that many of the industrialised nations have begun solving their tobacco problem. So this is I think the good news and the bad news. So I'll just give you a moment to let you take that in. This is the graph of, oops, sorry. This is a chart looking at smoking prevalence. So it's actually got cigarette consumption according to trillions of cigarettes per year and it's according to calendar year. So what you can actually see is very large amounts that have been smoked that have accumulated over the previous century. But we can actually see declines in a number of countries in Europe and America. This is charted according to the WHO regions. But what you can also see is that smoking in China is overwhelming smoking in many other parts of the world. The average Chinese smoker smokes around 22 cigarettes a day so it's not like smoking. And the amount consumed in China exceeds all of the low and middle income countries combined. If we look at the global burden of disease related to tobacco, it's the second leading cause of burden of disease after high blood pressure and above alcohol. It amounts to 6.3 million deaths per year. And that's actually more than 10% of the deaths worldwide are attributable to smoking. And we estimate that there's been about 100 million deaths attributable to tobacco in the 20th century and there will be 1 billion in the 21st century if we continue to go the way that we are going. And I think of all of the causes that are listed there it's readily preventable and it's getting worse. So we're probably going to go, if we keep on going the way we are it's going to go from 1 in 10 deaths caused by smoking to 1 in 6 worldwide. One of the other things we've noticed is that worldwide between countries and within countries it's increasingly concentrated in the poor and within the industrialised countries it's also increasingly concentrated among the mentally ill. In terms of the diseases that it causes this is also from the global burden of disease and if you look at the column here which is tobacco smoking these colours represent the particular diseases. So the dark blue is cancer, the middle is cardiovascular disease and chronic respiratory disease. And what you can see is that the main causes of the burden of disease there are spread across the increased risk of cancer, cardiovascular disease and chronic lung disease caused by smoking. So as I mentioned in the previous slide there are stages to any sort of cigarette epidemic and the risks related to smoking change over time. So this really shows a documented stages of the tobacco epidemic where these lines here about the percentage of male smokers then the percentage of female smokers and then the percentage of male deaths and the percentage of female deaths. And what you can see is sub-Saharan Africa is here at the moment. We're here at the moment which means we've had that surge in male smoking that's come down, the surge in female smoking that didn't quite get to the same level and it's fallen down here. And then you can see that there are a number of other places that are at this stage earlier in the epidemic. And what's quite sad is I mean quite clearly these countries don't have to go through the same thing that we went through. But unfortunately they seem to be doing that. So here's the success story in Australia. Australia has long been regarded as a dark market and it's really because of our outstanding tobacco control. And I think there are a number of people in the room who've contributed to that over time. We now have a rate of adult smoking of around 13% daily smokers which is among the best in the industrialized world. But it's down from a peak of around three quarters of men in the 1940s and around a third of women that peaked in 1978. And there are a number of different reasons why we have this outstanding levels of tobacco control. The main things that to do with price and also legislation about when you can smoke. And then as you know we've recently had the introduction of plain packaging. And it's been terrific to be an Australian talking about smoking internationally because there's massive interest in the plain packaging. But also I think that tobacco control measures are one of Australia's great exports but it's not really widely acknowledged. One of the interesting things is if you look at the US packet, I actually have one in one of the earlier slides. But it just looks like that I don't know if you remember the old kind of mulberry packet. And then it says in gold writing on a white background, Surgeon General's warning, cigarette smoke contains carbon monoxide. So obviously the air contains carbon monoxide. That's not a particularly strong health warning. But you can see that the Australian health warnings are really quite graphic. But in spite of this, this is the success story. But the success story means we actually have 2.7 million smokers in Australia. So there's quite a lot of dialogue about moving to the tobacco end game. Particularly the idea that once we get below 5% smoking, tobacco will become much more of a marginal activity. Smoking will become much more of a marginal activity. And then there's a whole debate about what kinds of strategies you can use beyond that point. So in keeping and in concert with those reductions in smoking and a number of other measures such as better control of blood cholesterol and better control of blood pressure, Australia now has the most outstanding record in terms of premature mortality, particularly in men. So if you look at the graph here on the left, you can see that the green is Australia and the blue is Japan. So you can actually see that in the late 1990s Australia actually overtook Japan in terms of premature mortality in men. In this age group we look at it's age group 35 to 69. It's a sort of sentinel age group that we look at for premature mortality. There's only one country doing better than Australia in this regard and that's Iceland. So in terms of our premature mortality and that has a reasonably large contribution to that is our tobacco control. So even though we have this extraordinary record in tobacco control, we didn't actually have any large scale data for Australia about what smoking was doing to our death rates. So this study was actually, the protocol was written for it in 2003 and then a huge effort went into data collection over the ensuing 10 year period. So you can see that it's been a really large effort and a large team involved. So the aim was to investigate the relationship of smoking to all cause mortality and by that I mean, regardless of cause, so it adds together cardiovascular disease deaths, cancer deaths, deaths from any cause in Australia in the 45 and up study cohort. So the 45 and up study cohort is a cohort of around 267,000 men and women who were recruited from the New South Wales general population from 2006 to 2009. They were aged 45 and over and we had around an 18% response rate. So that actually meant we had around 10% of the whole state were actually in the study. They completed a self-administered baseline questionnaire and they gave consent for linkage to health records. So in terms of the methods, I won't bore you with the statistical details but it's essentially a cohort study and that is where you sort of recruit people at baseline and you follow them over time. You ascertain their exposure at baseline, you follow them over time to see what happens to them. And in this case it's a bit ghoulish but we just waited for them to die basically. We excluded anyone who had missing data on smoking and we also excluded people who were sick at baseline because people who were sick at baseline would tend to have actually changed their smoking behaviour. They call that the sick quitter effect. So you actually find that your current smokers are depleted of people who are actually ill at the time because they've given up because they're sick. We followed up through the register of births, deaths and marriages to mid-2012. Tobacco smoking was ascertained on the questionnaire by asking the question, have you ever been a regular smoker? And then sub-categorising people according to how old they were when they started, whether they were currently a smoker, what age they were if they quit if they had quit and then how many cigarettes they smoked per day. And this is a question that's similar to other large-scale studies internationally. This gives you a sort of schema of the way that we looked at it. This is when they completed their baseline survey and we followed them, that was over the time they completed their survey and then we had the linked data on death all the way up to 2012. We also looked backwards at their hospital records for some analyses so that we could actually exclude people who had chronic respiratory disease. It's called a sensitivity analysis. It was just to really check that our findings were robust. So we used for the statistical methods, we used Cox proportional hazards modelling with age as the underlying time variable and we adjusted for a number of factors which might influence the relationship of smoking to mortality. We also estimated the effect of smoking on people's life expectancy and we looked at men and women separately and we also looked according to year of birth. So we looked at people born in different decades to see if the effect of smoking on mortality varied and that was really to look at whether we had a stable epidemic of smoking and we did, as I said, a number of sensitivity analyses to just check our findings were robust. So we ended up with over 200,000 participants after we'd excluded those people and because we'd followed them for 4.3 years we had what's called a total of 874,000 person years so that's really multiplying each person by the amount of time we had for them. There were around 5,600 deaths and this graph here shows the proportion of current smokers, former smokers and never smokers and what you can see is in keeping with the low rates of smoking in the general population and also the fact that this group is 45 and over we only had about 8% current smokers so it's actually a pretty low proportion of the population current smokers and these are the main findings. So this vertical line here is the line of no effect and this blocks to this side indicate an increased risk compared to the reference group and if we had any blocks this side it would indicate a preventive effect. This is the never smokers so we're always comparing people who smoked to people who had never smoked and what you can see first is for men we found that men who were current smokers had around 2.8 times the risk of dying during that follow-up period than men who had never smoked and for women it was around 3.1 compared to that risk of people who had never smoked. People who were former smokers didn't have a risk that it was as high as current smokers but they had an increased risk compared to the people who had never smoked and if you compare the men and women this is called the confidence interval which is really the range that that estimate would be expected to be in there's no significant difference between men and women in terms of the risks of mortality related to smoking so the general adage is if women smoke like men they'll die like men there used to be ideas that wouldn't happen so then this is a very busy slide but it's really looking at risks according to birth decade so these are people born in 1920 to 1929 and these are the more recent people born more recently in 1950 to 1959 so those same relative risks looking in the never smokers former smokers and current smokers and the only thing to take home there is actually the risks and patterns were very similar so what that suggests is actually there's a stable epidemic it doesn't really matter what decade you're born in if you are a long-term smoker your risks of dying are similar compared to people who had never smoked so and that's really a product of the fact that people who are smoking now have been smoking for a long time there's a general stabilisation in the age that people commenced smoking so if you imagine back in the 60s quite a lot of people who smoked in the 60s actually started smoking when they were in their 20s and they hadn't smoked for very long we just think that the people who are in 45 and over now pretty much all of them started smoking in their mid to late teens and they've smoked quite heavily that whole time so we've got this sort of actual it's got a realisation of the true hazards of smoking this is the age standardised rates of all cause mortality according to the intensity of smoking so this is the number of cigarettes per day this is zero cigarettes per day and these are people who are smoking around a pack of cigarettes per day the bottom line is women and the top line is men and what you can see from this is that as you smoke more your death rates increase you can also see that men in general have higher death rates than women but what's really interesting is a lot of people who would consider themselves to be light smokers those smoking 14 or fewer cigarettes a day actually have a doubling in their risk of dying during the follow up period and that's actually similar to the risks of dying related to being morbidly obese so it's similar to having a body mass index of 35 or more and also the relative risk of death associated with drinking a bottle of vodka a day so I think people when they think that they're a light smoker they do really tend to underestimate how lethal smoking is that's not to say you should drink a bottle of vodka a day by the way and when you're talking about people who smoke 25 cigarettes a day or more you're really looking at a 4 to 5 fold increase in the risk of death over the follow up period so here's the good news this is about what happens if you quit so this line here is the relative risk for never smoking relative risk for never smokers this is the line for current smokers and this is the age at stopping smoking and what we've done here is to plot the relative risks in people who quit smoking at these different ages and we didn't really go up beyond age 45 because you also get into the sort of sick quitter effect there that people tend to be quitting if they're sick so what you see here is that quitting at any of these ages and even if we were to continue at these ages is much much better than continuing to smoke but also if you quit before age 45 your risks don't differ significantly compared to someone who had never smoked so that's not to say that you should smoke your heart out until you get to 45 and then stop but it is saying that actually you can avoid a huge proportion of the excess mortality risks if you give up smoking by the age of 45 this is applying all of those relative risks to a typical life expectancy in Australia for men and for women and what you can see is that 45% of male smokers will be dead by the age of 75 compared to around 19% of people who had never smoked and you can see for women it's around a third of smokers will be dead by the age of 75 compared to around 12% of people who had never smoked and on average smokers lose around 10 years of their life expectancy so this is the risk of all cause mortality for the next analysis that we're going to be doing we will be looking at cause specific mortality but we've been waiting for data from the Australian Bureau of Statistics but we do know from other data that the excess deaths in smokers are by and large caused by smoking so it's easier to name the parts of the body that are not affected by smoking than it is to name those that are affected this is a sort of stylised list of all the parts of the body that are affected by smoking these are data from the Million Women's Study which Simon has already mentioned and what they show is the relative risk of death according to different causes and so you can actually see for chronic lung disease it wasn't actually able to be fitted on this graph it's around a 35 fold increase in the risk of death from chronic lung disease in smokers compared to non-smokers then you come to around a 21 fold increase in cancer of the lung and many many other conditions and this one here is coronary heart disease which has around a 5 fold increase in risk so we do know that when we observe that increased risk of premature mortality in smokers that the vast majority of those will be caused by smoking so the conclusion that we can come to from these first Australian findings are first of all there's a low prevalence of smoking and we already knew that from a lot of data from Australian Bureau of Statistics we also know that the relative risk of dying during follow-up in the current smokers is three times that of never smokers and this actually means that up to two thirds of the deaths in smokers can be directly attributable to smoking that means of the 2.7 million smokers in Australia around 1.8 million of them would be expected to die from their habit if they continue to smoke it also shows that the benefits of quitting are large particularly compared to continuing to smoke the earlier the better you quit and around 10 year estimated average reduction in life expectancy for smokers compared to people who have never smoked now I just want to talk a bit about the comparison with the international data and also comparison with what we already knew because as I said before it says it on the packet so it's important to know how these data contribute so as I've said there is variation in the relative risk of mortality that figure of three fold varies according to country and varies according to time and it's influenced by a variety of factors particularly it's influenced by smoking patterns so in places where the population has only taken up smoking relatively recently and people smoke small amounts the relative risks related to smoking are less the other thing is in countries with very high death rates in never smokers you actually find there's less of a difference between the smokers and the non smokers so when we look back at this cigarette epidemic I'm just going to take you through using the British doctor's study the relative risks relating to this overall epidemic but you can imagine that if you're comparing the death rates here between the smokers and the non smokers that you'll actually end up with a narrow world, you'll end up with it being narrow earlier in the epidemic so if we look at the British doctor's study which was a study led by Professor Sir Richard Dole and this is the 50 year follow up so it was the very earliest study to actually follow people forward who were smokers and to look at the risks of lung cancer and of death and Sir Richard Dole was a smoker when he did his first studies but when he saw his first cross tabulation we call it when he first looked at the risks in smokers and non smokers he stopped that actual day so that's evidence into practice so what you can see here is that during the 1950s and 60s the age standardised mortality rate in the lifelong non smokers was about 80 and in the cigarette smokers it was 93 and so the ratio of those rates is 1.2 so instead of the three fold difference it was 1.2 when you get to the 1980s it's around 2 the relative risk and then when you get to the 1990s it's around 3, it's around what we find so it's this evolution of risks and what you can see is for the lifelong non smokers the age standardised death rate went from 80 to 40 so it's actually even in the non smokers all the other improvements in health cause that big drop in mortality and it's particularly driven by drops in cardiovascular disease mortality but a lot of other things like injuries, accidents look at what happened in the cigarette smokers it actually increased so you can see why that gap between the current smokers and the non smokers changed so how does our finding of the three fold increasing risk compare with the international data? well I find it quite amazing how well it lines up if you consider that our data were from the general population of New South Wales but we're filling in a questionnaire and being followed over time so if you look at Richard Dole's findings the relative risk in men in current versus never smokers is around 2.83 we get 2.82 so it's remarkably similar if you look in women the million women study gets around 2.8 studies from the US both 3.0 and 2.8 and we get around 3.1 so and what they find is also around two thirds of deaths are attributable to smoking so remarkably similar results and the reason these are similar is that all of these places so the UK and the US also has a mature epidemic of smoking so they're at that stage four in the epidemic where they've actually realised the sort of general consequences of smoking all of the smokers have started smoking at a young age they smoked intensively and so the adverse effects are quite similar they also find and I won't take you through all of these graphs but these are all of the ones looking at life expectancy and it's actually fairly consistent a 10 year reduction in average life expectancy as well so how does the evolution of smoking risks really pan out? well if you look at the proportion of smokers likely to be killed by smoking it was around one in six in the 1960s around half in the 1980s and we're now up to two thirds so in the 1960s it was like throwing a dice in the 1980s it was like tossing a coin and in the well the 21st century I didn't quite know what to say at this point but I think it probably is that it's time to stop gambling because really at this point the odds are stacked against you and I suppose I think this then brings us to the point of why magnitude matters why does it matter that instead of it being a half which is really the estimates that we've been using worldwide and we're now up to two thirds and obviously these findings came out in February so it's not really translated yet into the general consciousness why is it different? why does it have half versus two thirds? and I think the first thing is that there's a lot in our consciousness about the balance of probabilities I think if something is 50-50 it means something quite different from it being two thirds and that's true in law, in civil law but it's also I think a realisation that you're unlikely to get away with it and at the same time as really highlighting that the harms are greater than we thought it also means that the benefits of quitting are greater than we thought and the other thing it means is if one person quits or if you support one person to quit the chances are you've actually saved a life and I think that it's not often that we have policies and regulations that save lives but I think that if the ANU going smoke free actually encourages one person to quit you'd be pretty sure that you've actually contributed to someone not having a premature death so I would say here that it does matter that magnitude matters and that there is a big difference between half and two thirds you can see that this is the US cigarette packet with the gold writing on the white background and you can contrast that with the Australian one where it's graphic in the extreme so how do we get here? Well the first thing is that smoking is highly addictive there are plenty of examples of people who've managed to quit heroin who've not been able to quit smoking the other thing that is that we're in this situation really for historical reasons so smoking became widespread and it became embedded in a lot of cultures at a time when we really didn't know that it was harmful and as you can see here there was quite a belief that actually smoking was good for you so when smoking really took off but it is true that the majority, the vast majority of smokers wish that they had never started so people also tend to take on smoking at a time when they're not really thinking about the long term effects and it's very very difficult to quit the other thing is that as a product cigarettes were introduced at a time when our regulation system our regulatory system was not as strong so if you imagine now going to the FDA saying I've got this product it's going to kill about two thirds of the people who do it they'll take it up when they're kids you know there's pretty much no part of the body that it doesn't harm what do you reckon? so you can see that at the time when it was really grandfathered it's been sort of grandfathered and it was introduced it was passed by the FDA I think in the early part of the 20th century so it was really a time when things like this could get through and the other thing it speaks to actually is our priorities because by allowing, I mean it is actually an industry people are actively profiting from it and you can say there are components of that in other health problems but it's not the same this isn't like an Ebola outbreak or a tsunami it's actually companies actively marketing this in order to make a profit and their mission is to make more people smoke so we have chosen in whatever way to prioritize that ability to trade and that ability to make money over health in a lot of different settings so this is a photo of the house of the former CEO Australian CEO Philip Morris at the time it went to auction it was expected to fetch $45 million so I do sometimes ask how people sleep at night but I think they sleep with the sound of the ocean sometimes so in terms of the use of these findings they're clearly part of a broader longer effort and I think there are plenty of people in this room who can really tell the story of that effort so it's really just one part of a much bigger picture but I have to say that there was enormous excitement among tobacco advocacy, tobacco control advocacy people about the fact that we would finally have Australian data and there was also a recognition that the release of this evidence was in itself a public health action so that you could just sort of publish it quietly and maybe hope the media would pick it up but that probably wouldn't have the kind of impact than if it was sort of integrated into a more general awareness so a lot of planning went into actually releasing the findings in a way that would maximise their impact we had partner organisations actually embedded in the research so we had people from the Cancer Council and the Heart Foundation actually who were authors on the paper and we worked with them to look at the best ways of framing the evidence we also had early consultation with the key players they're also known as the usual suspects these people and in fact Simon Chapman, when he was talking about the plane packaging he did say that the one thing was missing was a scratch and sniff thing which had the smell of rotting lungs in it so he's... and Michael Moore was here so he's one of the people that we contacted as well Mike Dorb was particularly helpful in terms of framing things about the numbers of smokers and the numbers of smokers who'd be likely to die if they didn't quit we actually also had a really very specific written media strategy about who to approach, how and how to do it and there were multiple press releases that came out so I'll just give you some examples of what happened so we did end up with over 900 media articles and I understand that that's actually considered pretty good we had a lot of national and international interest across the board and we're actually quite interested in monitoring whether this particular release of findings actually had an impact on quit rates because often research per se doesn't necessarily have an impact but we're just interested to see if one kind of shock like that can actually have an impact coinciding with the Western Australian actually and ACOSH which is a coalition of anti-smoking groups put out a full page ad in the Western Australian really just highlighting that the news was worse than people thought and we've also been following just different bits and pieces of people picking up on the findings to use them for their work so I had a conversation with someone who said that quit Victoria had been saying that it's been enormously helpful for their work to be able to cite Australian data and this is one of my favourite examples of policy translation so Bronwyn King is a radiation oncologist who was working on a daily basis with people who were dying from lung cancer but she was horrified to find that her Superfund was actually investing in tobacco so she then went to her Superfund and said have you considered divesting and since that time she's actually convinced 28 Australian Superfunds to divest at least $1.3 billion from tobacco companies and when I went to the meeting she sort of collared me and said I use your findings every single day I use them with my patients and I also use them in my tobacco divestment work and she also highlighted the importance of having Australian data about the Australian epidemic so I think that brings me now to the ANU Smoke Free and I particularly like this picture because I think the clarity of the air in Canberra and the clarity of the air in this picture really highlights the perfect still autumn day I think that the smoke free policy really highlights the importance of having not only those high level policies that are to do with regulation particularly in terms of tobacco price where people can smoke but it's going to make no difference if we don't have that granular effort that effort of individual people to quit smoking and individual people to work to help people to quit and also people to resist the pressure to smoke so I think that I'd like to conclude particularly by acknowledging the people who are really putting in the hard yards to actually keep us on track and particularly I'm particularly grateful to the ANU for actually putting the money where their mouth is and I'd also like to acknowledge all the people who've made this possible I know that the protocol was written in 2003 but if you think about all the person years that each one of those participants put in it's been an enormous effort I'd particularly like to acknowledge and embarrass Grace Joshy who's just there in the audience she actually did all of the analyses and it's one of the great things for ANU is to have really, really top notch statisticians so I can go to Oxford happily with the findings and know that they'll stand up to that test really terrific team and all of the different organisations who supported the study itself and I'd particularly like to thank the ANU because one of the consequences of doing something that other people think is obvious and doing research where it says it on the packet is that you're absolutely dependent on your institution which supports researchers rather than individual research findings and who can see the value above and beyond sort of whether something is perceived as normal and I think that that really takes us beyond research and a well into action thank you