Review of 2021 Census Topics

Our submission is supported by these organisations:
Aboriginal and Torres Strait Islander health organisations (including the majority of Aboriginal community controlled health organisations with regional tobacco teams):
National Aboriginal Community Controlled Health Organisation
Redacted text, National Coordinator Tackling Indigenous Smoking program
Anyinginyi Health Aboriginal Corporation, Tennant Creek, NT
Apunipima Cape York Health Council, Cairns, QLD
Awabakal, Newcastle, NSW
Bullinah Aboriginal Health Service, Ballina, NSW
Carbal Medical Services, Toowoomba, QLD
Central Australian Aboriginal Congress, Alice Springs, NT
Danila Dilba Biluru Butji Binnilutlum Health Service, Darwin, NT
Flinders Island Aboriginal Association, Flinders Island, TAS
Galambila Aboriginal Health Service, Coffs Harbour, NSW
Institute for Urban Indigenous Health, Brisbane, QLD
3
Katherine West Health Board Aboriginal Corporation, Katherine, NT
Kimberley Aboriginal Medical Service, Broome, WA
Lakes Entrance Aboriginal Health Association, Lakes Entrance, VIC
Maari Ma Health, Broken Hill, NSW
Miwatj Health Aboriginal Corporation, Nhulunbuy, NT
National Centre of Indigenous Excellence, Sydney, NSW
North Coast Aboriginal Corporation for Community Health, Maroochydore, QLD
Nunkuwarrin Yunti of South Australia, Adelaide, SA
Pangula Mannamurna, Mt Gambier, SA
Puntukurnu Aboriginal Medical Service, Newman, WA
South Coast Aboriginal Medical Service, Nowra, NSW
Victorian Aboriginal Community Controlled Health Organisation, Melbourne, VIC
Victorian Aboriginal Health Service, Melbourne, VIC
Wellington Aboriginal Corporation Health Service, Wellington, NSW
Health professional associations:
Australasian Epidemiological Association
Australian Dental Association
Australian Health Promotion Association
Australian Medical Association
Public Health Association of Australia
Royal Australian College of General Practitioners
Royal Australasian College of Physicians
Thoracic Society of Australia and New Zealand
Health and welfare organisations:
Asthma Australia
Australian Council of Social Service
Australian Council on Smoking and Health
Cancer Council Australia
Lung Foundation Australia
National LGBTI Health Alliance
Stroke Foundation
Victorian AIDS Council

We propose a question on smoking status among Australians aged 15 years and older in the 2021 Census.
The rationale for adding this question has been described in a recent editorial in the Australian and New
Zealand Journal of Public Health.1
Even though national smoking prevalence has decreased, smoking remains a leading cause of
preventable death and disease.
The inclusion of a question on smoking prevalence in the Census was one of the recommendations of the
National Preventative Health Taskforce in 2009.2 Regular population surveys such as the National Health
Survey3 and the National Drug Strategy Household Survey4 provide reliable data on national trends in
smoking prevalence, and the Aboriginal and Torres Strait Islander Health5 and Social Surveys6 on national
trends in the Aboriginal and Torres Strait Islander population. However, the capacity of such surveys to
provide reliable estimates for sub-groups with known high smoking prevalence is limited. Given the
Census includes almost the entire population, it would allow more detailed analyses of the social
patterning of smoking with no sampling error. Census data would enable accurate estimates of smoking
prevalence for small geographical areas and small sub-populations. This has become increasingly
important as smoking becomes more concentrated in disadvantaged groups, and as tobacco control
increasingly needs to use streamlined approaches.7
The inclusion of a smoking question is practical. The ABS has accurately asked acceptable questions
about smoking in population health surveys for decades.3,5 Two questions on smoking have been
included in the past three New Zealand Censuses.8

Even though national daily smoking prevalence has decreased to 12% of Australians aged 14 and over,4 smoking is still responsible for 9% of Australia’s burden of disease, more than any other risk factor.9 All Australian health ministers have endorsed Australia’s National Tobacco Strategy.10 Australia has committed to monitoring trends in smoking as part of its obligations as a signatory to the World Health Organisation’s Framework Convention of Tobacco Control.11 As Australian tobacco control moves towards the ‘Endgame’, increasing policy attention is on smaller disadvantaged groups with higher smoking prevalence.
Census data on smoking prevalence would allow more detailed analyses of smoking patterns in small population groups and geographic areas than is possible with existing datasets (see criteria 2 below for further detail). This is important to support development of targeted tobacco control initiatives and to monitor the impact of existing programs. An example is the national Tackling Indigenous Smoking program, which spends most of its funding on 37 regional teams.12 Currently, these regional teams do not have accurate local data that allows policy-makers to assess progress or to evaluate progress compared to areas without regional teams. Census data would meet this need and the similar needs for developing and monitoring tobacco control initiatives for other population sub-groups, such as Australians from various cultural and language backgrounds or with severe economic disadvantage.
In the National Tobacco Strategy, policy makers have prioritised strengthening tobacco control activities among populations with a high prevalence smoking.13 While it is difficult to isolate what factors have led to decisions about the distribution of tobacco control resourcing and activities, there is some evidence that smoking prevalence data can be influential and that more detailed data from a Census question is needed. The experience from the national Tackling Indigenous Smoking program supports this. The recent ABS report documenting improvements in Aboriginal and Torres Strait Islander smoking and quitting has been frequently stated by Australian Government Department of Health policy makers as critical in the $184m decision to extend the Tackling Indigenous Smoking program for 4 years.13 This data was featured in the Minister’s media release announcing the funding.14 This program has also called for a large tender for more precise and nuanced regional data collection, which would suggest that these policy makers would be very keen to use the more detailed smoking prevalence data that would become available with a question in the census.
Smoking is a risk factor for almost every chronic disease15, and therefore provides a reliable indicator of likely long-term future health care needs. Smoking is also a clear marker of social disadvantage, and may provide a better measure of persistent disadvantage than income or area based measures of socio-economic status.16 As a result, smoking status will also provide a good indicator of social service needs in particular areas into the future.
The Census data on smoking could also be used for important epidemiological research on smoking, as has occurred in New Zealand. The New Zealand Census-Mortality Study has linked census and mortality data, enabling the census smoking data to be used by researchers to determine mortality among non-smokers living with smokers; the changing smoking-mortality association over time across social groups; and the contribution of smoking to mortality inequalities. 17 18 19 20 In Australia, the 2011 Census has been linked with death registrations, with similar plans for future Censuses, thereby enabling similar research to that conducted in New Zealand if a smoking question is added to the Australian Census.21

Census data on smoking prevalence would enable more accurate measures of smoking prevalence for population sub-groups and small geographic areas where smoking prevalence is high. These include Aboriginal and Torres Strait Islander populations; Australians from various cultural and language backgrounds; those who are severely economically disadvantaged; and sub-groups of the Lesbian, Gay, Bisexual, Trans, Intersex and Queer (LGBTIQ) population. All these sub-groups can be identified by other characteristics collected in the Census.
The best available smoking prevalence data for Australia currently come from two population health surveys: the National Drug Strategy Household Survey (NDSHS, conducted by the Australian Institute of Health and Welfare)4 and the National Health Survey (by the ABS)3. These surveys provide similar descriptions of the downward trend in national smoking prevalence - however the survey estimates for Aboriginal and Torres Strait Islander smoking prevalence highlight the limitations of population health surveys in understanding smoking prevalence in sub-groups, where smoking is now increasingly concentrated.
The 2016 NDSHS estimate of daily smoking prevalence among Aboriginal and Torres Strait Islander people aged 15 and over was 28% compared to 39% in the 2014-15 National Aboriginal Torres Strait Islander Social Survey conducted by the ABS. The large NDSHS included a much smaller and less representative sample of Aboriginal and Torres Strait Islander people (only 568 participants aged 12 and over). While the ABS Aboriginal and Torres Strait Islander surveys address this limitation for estimates of the national Aboriginal and Torres Strait Islander smoking prevalence, these limitations remain for smaller geographic and age sub-groups of the Aboriginal and Torres Strait Islander population.
Unlike the Census, neither of the population surveys captures smoking prevalence among Australians who are homeless or living in non-private dwellings (eg. hotels, hostels, hospitals and prisons). Accurate information about smoking in these sub-groups excluded from population surveys is important to guide policy to support tobacco control initiatives where smoking is very prevalent.
Researchers in New Zealand have found that while microsimulation models can provide smoking prevalence estimates for small areas and subgroups, these are not yet sufficiently accurate.22

The ABS (and AIHW) has decades of experience in asking questions about smoking in population health surveys. Smoking questions can be easily understood by respondents, and do not require a high degree of literacy or language proficiency.
However, any question is open to error and bias, especially if completed by another householder. We are confident that a suitable smoking question, or series of questions, could be selected after the usual ABS development and piloting processes which would continue to provide valid and reliable estimates over time, and be simple and quick for respondents to answer.

Smoking questions are likely to be considered acceptable to all respondents.
There are decades of experience in asking questions about smoking in Australian population health surveys. Very few respondents choose to not respond to these smoking questions or respond that they don’t know the answer. Similarly, very few respondents have not responded to the two smoking questions in the New Zealand Census.

The ABS (and AIHW) has decades of experience in asking questions about smoking efficiently in population health surveys. A single smoking question, or a series of questions, could be answered with check boxes and without the need for a large number of response categories or text responses. The responses could be simply collated and reported as for the population health surveys.

Even though national smoking prevalence has fallen to 12%, monitoring smoking prevalence is likely to remain a major public health priority in the future. Australia will remain committed to monitoring trends in smoking as part of its obligations as a signatory to the Framework Convention on Tobacco Control.
As we move into the tobacco control ‘Endgame’, accurate monitoring of progress in small population groups will become even more important, but only practical with the Census. This Census data would inform important policy and program decisions in the long term.

Additional information to be gleaned from analyses of a smoking question in future Australian Censuses is not possible with existing population health surveys (or using microsimulation modelling).
These population surveys would continue to complement the Census by providing more frequent monitoring of national trends in smoking prevalence and more nuanced understanding of smoking and quitting behaviours and attitudes.

We have attached a copy of the recent editorial ‘Should a smoking question be added to the Australian 2021 census?’ from the Australian and New Zealand Journal of Public Health.
References
1 Thomas DP and Scollo M. Should a smoking question be added to the Australian 2021 census? Aust N Z J Public Health. 2018;42:225-26. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/1753-6405.12788
2 Australian Government Preventative Health Taskforce. Australia: the healthiest country by 2020. Technical Report No 2, Tobacco control in Australia: making smoking history. Canberra, Australia 2009. Available from: http://www.health.gov.au/internet/preventativehealth/publishing.nsf/Content/96CAC56D5328E3D0CA2574DD0081E5C0/$File/tobacco-jul09.pdf.
3 Australian Bureau of Statistics. 4364.0.55.001 National Health Survey: First Results, 2014–15. Canberra: ABS; 2016. Available from: http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4364.0.55.001Main+Features100012014-15?OpenDocument
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