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Public Health Effects
of Tobacco Dependence
Lars M. Ramström
Institute for Tobacco Studies
Stockholm, Sweden
Number of deaths (’000s) in 1998
attributable to tobacco use
WHO Region
Males Females
All member states
Africa
The Americas
Eastern Mediterranean
Europe
South-East Asia
Western Pacific
World Health Report 1999
3,241
112
472
160
1,066
505
927
782
13
300
22
207
75
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)
% of
deaths
Malnutrition
0.0
Poor water, sanitation
0.0
Unsafe sex
0.8
Tobacco
14.9
Alcohol
1.2
Occupation
2.2
Hypertension
11.1
Physical inactivity
11.7
Illicit drugs
0.4
Air pollution
0.9
Risk factor
% of
DALYs
0.0
0.1
2.0
11.7
10.3
5.0
3.9
4.8
2.3
0.5
Deaths respectively DALYs
attributable to selected
risk factors in 1990.
World as a whole
% of
% of
deaths 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
Risk factor
Source: Murray CJL, Lopez AD. 1996.
DALYs attributable to tobacco use
% of total in
Region
1990
2020
World
Developed Regions
Developing Regions
2.6
12.1
1.4
8.9
18.2
7.7
Source: Murray CJL, Lopez AD. 1996
DALYs attributable to tobacco use
% of total in
Region
1990
2020
Est. Market Economies 11.7
Former Socialist Econ.
of Europe
12.5
India
0.6
China
3.9
Sub-Saharan Africa
0.4
Latin America & Carib.
1.4
17.0
19.9
10.2
16.1
1.7
6.8
”By 2020, tobacco is
expected to cause more
premature death and
disability than any
single disease.”
Murray CJL, Lopez AD. 1996
Why do people smoke?
• Initiation - social reasons
• Maintenance - pharmacological reasons
P. Hajek 2001
Smokers have low degree of
control over their behaviour
• 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
P. Hajek 2001
Are smokers addicted?
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
P.Hajek 2001
WHO ICD 10
International Classification of Diseases
F10-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)
NOW
SUMMARY (1)
Among 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 of
premature deaths and DALYs
IN THE WORLD AS A WHOLE:
Tobacco comes second only to malnutrition as a cause of
premature deaths
BY 2020
Tobacco is expected to cause more premature deaths and
disability 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 of
reduction of smoking-related disease and disability