Number of deaths (’000s) in 1998 attributable to tobacco use WHO Region Males Females World Health Report 1999 All member states3,241782 Africa 112.

Public Health Effectsof Tobacco Dependence

Lars M. RamströmInstitute for Tobacco Studies

Stockholm, Sweden

Number of deaths (’000s) in 1998 attributable to tobacco use

WHO Region Males Females

World Health Report 1999

All member states 3,241 782

Africa 112 13

The Americas 472 300

Eastern Mediterranean 160 22

Europe 1,066 207

South-East Asia 505 75

Western Pacific 927 166

A measure of burden of disease capturing the impact of both premature deaths and disability

DALYs

Disability Adjusted Life Years

One DALY is one lost year of healthy life

Deaths respectively DALYs attributable to selected risk factors in 1990.

Established Market Economies ( OECD)

Risk factor % of deaths

% of DALYs

Malnutrition 0.0 0.0 Poor water, sanitation 0.0 0.1 Unsafe sex 0.8 2.0 Tobacco 14.9 11.7 Alcohol 1.2 10.3 Occupation 2.2 5.0 Hypertension 11.1 3.9 Physical inactivity 11.7 4.8 Illicit drugs 0.4 2.3 Air pollution 0.9 0.5

Deaths respectively DALYs attributable to selected risk factors in 1990.

World as a whole

Risk factor % of deaths

% of DALYs

Malnutrition 11.7 15.9 Poor water, sanitation 5.3 6.8 Unsafe sex 2.2 3.5 Tobacco 6.0 2.6 Alcohol 1.5 3.5 Occupation 2.2 2.7 Hypertension 5.8 1.4 Physical inactivity 3.9 1.0 Illicit drugs 0.2 0.6 Air pollution 1.1 0.5

Source: Murray CJL, Lopez AD. 1996.

DALYs attributable to tobacco use

% of total in

Region 1990 2020

World 2.6 8.9Developed Regions 12.1 18.2Developing Regions 1.4 7.7

Source: Murray CJL, Lopez AD. 1996 DALYs attributable to tobacco use % of total in

Region 1990 2020

Est. Market Economies 11.7 17.0 Former Socialist Econ. of Europe 12.5 19.9

India 0.6 10.2China 3.9 16.1Sub-Saharan Africa 0.4 1.7Latin America & Carib. 1.4 6.8

Murray CJL, Lopez AD. 1996

”By 2020, tobacco is expected to cause more

premature death and disability than any single

disease.”

Why do people smoke?

P. Hajek 2001

• Initiation - social reasons

• Maintenance - pharmacological reasons

Smokers have low degree of control over their behaviour

P. Hajek 2001

• Most smokers say they want to quit

• Over 95% of smokers rarely if ever go a day without a cigarette

• Over 97% of quit attempts last <6 months

• Some 70% resume smoking after a major smoking related health crisis

Are smokers addicted?

Are smokers addicted?

P.Hajek 2001

Signs of addiction include

• Continued use despite knowledge of harmful effects

• Witdrawal symptoms and urges to use the drug during abstinence

• Failure of attempts to stop

WHO ICD 10International Classification of DiseasesF10-F19 Mental and Behavioural Disorders Due to Psychoactive substance use

F10 Disorders resulting from use of alcohol

F11 Disorders resulting from use of opiods

F12 Disorders resulting from use of cannabinoids

F13 Disorders resulting from use of sedatives or hypnotics

F14 Disorders resulting from use of cocaine

F15 Disorders resulting from use of other stimulants

F16 Disorders resulting from use of hallucinogens

F17 Disorders resulting from use of tobacco

F18 Disorders resulting from use of volatile solvents

F19 Disorders resulting from multiplw drug use and use of other psychoactive substances

Intervention strategies for reduction of tobacco-related death and disability

• Decreasing onset of tobacco use

• Increasing cessation

• Finding less harmful kinds of tobacco use

Less harmful tobacco use”Light” cigarettes ?Generally no benefit. Low nicotine yield may even

increase health risks unless tar/nicotine ratio is kept extra low

Smokeless tobacco ?Most kinds of smokeless tobacco involve severe

health risks. However, Swedish ”snus” (a special kind of moist

oral snuff) has been recognized as substantially less harmful than smoking

Intervention to decrease onset

Potential:In principle it represents a long term solution

Difficulties:It cannot yield an appreciable reduction of mortality

during the nearest 40 years - only later, when today’s young people reach ages >55

Social pressure to smoke can be very strong and intervention programmes have limited success

Intervention to increase cessation

Potential:Mortality reduction occurs quite rapidly after

successful intervention

Widespread cessation contributes to a social climate that favours prevention of onset

Difficulties:Smokers must be given both:- motivation to quit, and - support to overcome their dependence

Three intervention scenarios as basis for:

Projections of premature tobacco deaths for periods 2000-2024 and 2025-2049 Peto R. et al 1998

• No intervention (current trends persisting)

• Intervention to decrease onset (halving uptake of smoking by 2020)

• Intervention to increase cessation (halving global cigarette consumption by 2020)

SUMMARY (1)NOWAmong 10 selected risk factors for disease and disabilty(incl. e.g. malnutrition, alcohol, illegal drugs, unsafe sex)

IN THE DEVELOPED REGIONS:Tobacco causes the heaviest burden both in terms ofpremature deaths and DALYs

IN THE WORLD AS A WHOLE:Tobacco comes second only to malnutrition as a cause ofpremature deaths

BY 2020Tobacco is expected to cause more premature deaths anddisability than any single disease(if current smoking patterns persist)

SUMMARY (2)DURING THE FIRST HALF OF THIS CENTURY

The smoking-related burden of disease and disability:

– CANNOT be significantly reduced by prevention of onset

– CAN be significantly reduced by large scale smoking cessation

DURING THE SECOND HALF OF THIS CENTURY

– Current efforts to prevent onset start to reduce smoking-related disease and disability

– Smoking cessation continues to be a major means ofreduction of smoking-related disease and disability