Australia was an early innovator of applying indirect techniques6 to estimate the effects of tobacco, based on international estimates applied to local data. Using this approach, about 15% of deaths between 1998 and 2000 were attributed to smoking (about 19 000 of the 130 000 deaths per annum). These estimates have now been revised to 15 000 deaths per annum as a result of changes in the methods of estimation and assumptions about relative risk. Among male doctors in the United Kingdom, up to two-thirds (instead of, previously, half) of continuing smokers are now killed prematurely by their habit, and if these results are broadly generalisable, such estimates may need further revision. Yet, in New South Wales, there is an eightfold variation in men and a 16-fold variation in women in the risk of lung cancer, depending on their place of birth. With a quarter of the Australian population born abroad, continued reliance on indirect estimates inferred from Western studies is likely to be contestable. By contrast, great efforts are made to compute direct estimates of the burden of illness due to cancers, such as those of the cervix and breast, for which established screening programs exist.
Just as we obtain and rely on detailed information for other prevention programs, public policy on tobacco control ought to be based on equally accurate and direct information on the local contribution of tobacco smoking to leading causes of death (eg, vascular disease and lung cancer) and to other causes of death (eg, cancer of the liver, cervix, pancreas, bladder, oesophagus, head and neck, and kidney, together with myeloid leukaemia, as well as kidney disease, tuberculosis, and ulcers) known to be associated with tobacco smoking, and how these effects change over time. In absolute terms, deaths from these “other” causes of death exceed the number of deaths from lung cancer. In addition, some of these causes, such as liver cancer and kidney disease, are increasing in incidence, yet we have no precise idea of the contribution of tobacco smoking to their epidemiology. There is considerable debate about how to shape tobacco control programs for the part of the population that still smokes, whether current interventions will continue to work and, also, how to obtain reliable data from the increasingly marginalised and hard-to-reach segments of the Australian population among whom smoking is still common. Put simply, we are using yesterday’s tools to shape today’s policy on tobacco control. Without reliable information, future tobacco control policies will continue to rely on innovative yet blunt methods, and thus be compromised.
We agree with Peto and colleagues who have always insisted that direct approaches are required for making accurate and locally valid estimations of deaths caused by smoking tobacco. Direct approaches typically include large prospective studies. The 45 and Up Study has just completed enrolling 250 000 residents in NSW, but data on morbidity or deaths will take over a decade to accumulate. In New Zealand, questions on smoking have been ingeniously included in the national census and linked to death notifications. Important differences in tobacco-attributed mortality were found between Maori and non-Maori populations. Furthermore, these differences in risk attributed to tobacco were shown to evolve over time25 — the tobacco epidemic is not static.