Smoking and vaping on death notification forms in Australia: Improving the reporting of preventable risk factors

We are coming up to almost 60 years since the landmark US Report of the Surgeon General on The Health Consequences of Smoking1 that warned of the negative health impacts of smoking tobacco. While Australia as a nation has taken great strides in how to end the tobacco epidemic, we still have limitations in identifying tobacco and e-cigarette (vaping) attributed deaths as this information is not reported through our death notifications. For most people, Australia has one of the most complete and accurate death notification systems in the world. However, without important information on tobacco and vaping, there are limitations in understanding how these impact particular population groups as well as where resource allocation of health programs and policies that can improve public health and safety should go. Smoking is likely to kill prematurely two million out of three million Australians who are current smokers.2 However, estimates of tobacco attributed mortality are currently based on overseas risks, extrapolated to local smoking prevalence estimates.3 We have no accurate data on prevalence and outcomes to inform progress. This is of particular importance from an equity lens where there continues to be underserved populations in our communities who are disproportionately impacted by tobacco smoking and vaping including Aboriginal and Torres Strait Islander people, people with lower socioeconomic status and people who live in outer regional and remote areas. While there have been significant declines in the uptake of tobacco smoking for Aboriginal and Torres Strait Islander peoples,4 there continues to be higher prevalence rates of smoking than that of the general population.5 The impact of such requires greater focus. For these reasons and as an expansion of previous work, which asked about smoking habits five years before death,6, 7 we have rekindled efforts to introduce two voluntary questions on tobacco smoking and vaping on Australian death notification forms (see Box). This was first suggested by Peto and Doll in UK 19928 and in Australia in 2009.3 These questions have been implemented successfully elsewhere.9 South Africa now has data on over 3 million deaths to derive tobacco attributed trends10 and Tianjin has accurate, ongoing documentation (~70,000 cases per year) on the benefits of cessation,11 both providing local representative data to inform their national tobacco control programs. Smoking has been found to increase risk in all respiratory pandemics studied (MERS, SARS, H1N1-“Swine-Flu”) and epidemics of community acquired pneumonia, influenza and tuberculosis.12 Emerging evidence also shows an association between tobacco smoking and COVID-19 deaths.13 E-cigarette use is increasing14 and its early use is already associated with several serious lung and non-lung related outcomes,15 including COVID-19 and other respiratory infections. 16, 17 As well as rekindling an appreciation of the magnitude of the hazards of smoking and vaping on lower respiratory tract infections, the inequitable impact this has on people in lower socioeconomic groups has highlighted the need to provide systems that can work for all Australians The future health effects of current and long term e-cigarette exposures are yet to be charted. This is something that could be easily measured with the addition of questions on death notification forms. Having such locally derived population data will focus our policies and sharpen our narrative about how smoking and e-cigarette use kills in each community and enable us to reach further with more accurate messages and localised strategies to achieve our ambitious prevention targets. Death notifications are governed by regulations under the Births, Deaths and Marriages Registration Acts in each State and Territory which will need support from registrars in each jurisdiction. Including these questions on death notification forms will require minor low-cost modifications, and in all a small intervention in relation to the enormous benefits such information will yield. The advent of a new Australian Centre for Disease Control provides an opportunity to improve surveillance systems that are sub-optimal and optimise those that are well functioning. It also illuminates the importance of how health promotion is necessary for a holistic, comprehensive public health response in the making of an Australian CDC.18 These efforts have the potential to enhance national health promotion and public health policy. Adding two questions on smoking and e-cigarettes to the death certificate is a cost-effective enduring response to effectively improve monitoring and surveillance of the nation's greatest preventable risk factor.