Population growth results in more daily smokers globally, but robust tobacco control programs slow the pace
Several countries have shown remarkable progress in reducing the disabling effects and disease burden of tobacco smoking since 1990, demonstrating that progress is possible
Unless daily smoking is significantly reduced from current levels, the total number of smokers will continue to rise and place tremendous burden on health systems
SEATTLE – Despite strong declines in the rate of tobacco smoking over the past 25 years, one out of every four men still smoke daily, as do one out of every 20 women.
In a new analysis from the Global Burden of Disease study (GBD) published today (April 5, 2017) in The Lancet, authors discovered that the prevalence of daily smoking declined on a global scale – decreasing by 28% for men and 34% for women between 1990 and 2015.
But while the rate of smoking has fallen over the past few decades, the number of daily smokers globally continues to rise year-over-year due to population growth. As of 2015, there were 933 million daily smokers.
“Robust tobacco control efforts have led to progress in reducing the deadly habit of smoking in much of the world, but much more can be done,” said senior author Dr. Emmanuela Gakidou, Professor of Global Health at the Institute for Health Metrics and Evaluation (IHME) at the University of Washington in Seattle. “Growth in the sheer number of daily smokers still outpaces the global decline in daily smoking rates, indicating the need to prevent more people from starting the tobacco habit and to encourage smokers to quit.”
The three countries with the most male daily smokers in 2015 accounted for over half of all men who smoked daily worldwide. Countries with the most male daily smokers in 2015 were China with 254 million, India with 91 million, and Indonesia with 50 million.
The three countries with the highest number of female daily smokers in 2015 accounted for just over 25% of all female daily smokers worldwide. Countries with the most female daily smokers in 2015 were the Unites States with 17 million, followed by China with 14 million, and India with 13.5 million. These results suggest that the tobacco smoking epidemic is less geographically concentrated for women than for men, with implications that global efforts may need to be different to reach male smokers compared to female smokers.
In an effort to encourage governments to implement tobacco control policies, the World Health Assembly in 2003 adopted the WHO Framework Convention for Tobacco Control (WHO FCTC). The WHO FCTC has been ratified by 180 Parties and sets the path forward for implementation of robust tobacco control programs. To scale up implementation of the treaty’s key demand – reduction measures on the ground – in 2008 WHO established the MPOWER measures in line with the WHO FCTC, with a focus on cost-effectiveness, practicality, and impact.
“The WHO FCTC and its guidelines provide the foundation for countries to implement and manage tobacco control. The MPOWER measures help make this a reality and have changed the landscape of global tobacco control,” says Dr. Douglas Bettcher, Director of the Department of Prevention of Noncommunicable Diseases at WHO headquarters in Geneva. “Along with national and local governments and other partner organizations in high-burden countries, we are making positive change happen in some of the toughest tobacco industry strongholds. Together, we have protected nearly 1.8 billion people with at least one new MPOWER measure at the highest level of achievement since 2007.”
India has seen remarkable reductions in daily smoking. It became a Party to the WHO FCTC in 2005 and has created tobacco control initiatives. These include a ban on smoking in many public places and offices, bans on tobacco advertising in many forms, and requiring pictures of tobacco’s health effects that cover 85% of cigarette packaging. The pictures will begin to appear on cigarette packs later in 2017.
Since the initial rollout of programs and policies, India has seen marked drops in daily smoking. Daily smoking prevalence of Indian men fell by an average of 3% every year between 2005 and 2015, twice as fast as in the previous decade. For women, the change in daily smoking prevalence flipped from an alarming 1% yearly increase from 1990 to 2005, to a 2% decrease from 2005 to 2015. These estimates do not include smokeless tobacco, however, from which India still has a high burden.
Brazil, which also ratified the WHO FCTC and is a leader in tobacco control, saw the third-largest overall decline in daily smoking prevalence since 1990 – a drop of 57% for men and 56% for women. The country has implemented a combination of tobacco control policies, including advertising restrictions, smoking bans, and taxes on tobacco products.
The authors also examined the relationship between prevalence of daily smoking and development status – measured by using the Socio-demographic Index, which synthesizes income, education, and fertility rates. Daily smoking prevalence varied by sex and level of development. The highest smoking prevalence for men was observed in mid-level development countries, whereas the highest smoking prevalence for women was observed in highly developed countries. The lowest smoking prevalence for both men and women was observed in countries of the lowest quintile of development.
When looking at age trends, daily smoking prevalence was consistent across development groups for men, with the highest prevalence generally seen between ages 25 and 35. For women, however, age patterns were more varied across levels of development.
While countries with the lowest level of development generally showed the lowest prevalence of daily smoking, these countries have seen the greatest percent change in overall health burden in 2005 to 2015, mainly as the result of population growth.
“With sustained commitment to implementing proven measures to reduce tobacco use, governments can help curb a global epidemic projected to kill 1 billion people this century,” said Matthew L. Myers, President of the Campaign for Tobacco-Free Kids. “Countries that have acted decisively to implement policies like those called for in the FCTC have seen the most dramatic drops in tobacco use. Without urgent action, more than 80% of tobacco-related deaths will occur in low- and middle-income countries by 2030.”
There were 13 countries that sustained significant annual rates of decline between both from 1990 to 2005 and 2005 to 2015, including Australia, the United States, and Brazil. Further, the daily smoking prevalence declined faster between 2005 and 2015 in 18 countries, including Nepal, Chile, and Ukraine.
Smoking is the second-leading cause of death globally. More than 11% of all global deaths in 2015 were attributed to smoking, totaling 6.4 million. Over half of these smoking-related deaths took place in just four countries: China, India, the United States, and Russia.
In addition, daily smoking still contributes to a significant amount of the world’s overall health burden, measured using the disability-adjusted life years (DALYs) metric, which combines years of healthy life lost due to illness with those lost due to premature death. Most DALYs attributable to daily smoking were due to cardiovascular diseases (41%), cancers (28%), and chronic respiratory diseases (21%).
Countries with the highest number of deaths from smoking (rounded):
- China (1.8 million)
- India (743,000)
- US (472,000)
- Russia (283,000)
- Indonesia (180,000)
- Japan (166,000)
- Bangladesh (153,000)
- Brazil (149,000)
- Germany (130,000)
- Pakistan (124,000)
Countries with the highest prevalence of male daily smokers:
- Kiribati (48%)
- Indonesia (47%)
- Laos (47%)
- Northern Mariana Islands (46%)
- Armenia (43%)
- Greenland (43%)
- Belarus (42%)
- Ukraine (41%)
- Azerbaijan (40%)
- Timor-Leste (40%)
Countries with the highest prevalence of female daily smokers:
- Greenland (44%)
- Bulgaria (28%)
- Greece (27%)
- Montenegro (26%)
- Croatia (26%)
- Northern Mariana Islands (25%)
- Kiribati (25%)
- Macedonia (23%)
- Hungary (23%)
- Austria (23%)
“Data on smoking trends is essential to continuing the progress we’re making reducing the death toll from tobacco. The more we know, the better we can target our efforts, the greater incentive national governments have to take action, and the more death and disease we can prevent,” said Michael R. Bloomberg.
Michael R. Bloomberg has been a leading advocate in the fight against tobacco use. Bloomberg has provided nearly $1 billion to tobacco control efforts including 10 years of support for the implementation of tobacco control laws and policies around the world through the Bloomberg Initiative to Reduce Tobacco Use. To date the initiative has successfully supported 59 countries in passing laws or policies, reaching nearly 3.5 billion people and saving an estimated 30 million lives.
Daily smoking is defined in the study as the daily use of manufactured or hand-rolled cigarettes, cigars, pipes, hookah, bidis, and other country-specific smoked tobacco products, when applicable. Smokeless tobacco products and burden due to secondhand smoke were not included in the analysis.
The study was funded by Bloomberg Philanthropies and the Bill & Melinda Gates Foundation.
In addition to the study, IHME updated its data visualization tool to reflect data through 2015. The tool can be accessed at www.vizhub.com/tobacco.
The open-access research article, published in The Lancet, is available at www.lancet.com/gbd.
Established in 2007, the Institute for Health Metrics and Evaluation (IHME) is an independent global health research center within UW Medicine at the University of Washington in Seattle. IHME provides rigorous and comparable measurement of the world’s most important health problems and evaluates strategies to address them. IHME makes this information available so that policymakers, donors, practitioners, researchers, and local and global decision-makers have the evidence they need to make informed decisions about how to allocate resources to best improve population health. For more information, visit www.healthdata.org.