Int. J. Environ. Res. Public Health 2009, 6 210 globally the use of tobacco products is increasing (Figure 1), with the epidemic shifting to the developing world. More than 80% of the world’s smokers live in low and middle income countries. It is estimated that tobacco use kills 5.4 million people a year and accounts for 10% of adult deaths worldwide, with up to 50% of smokers dying from a tobacco-use related disease. Unchecked, tobacco- related deaths will increase to more than eight million a year by 2030, and 80% of those deaths will occur in developing countries. Tobacco use is a risk factor for six of the eight leading causes of deaths in the world including respiratory and cardiovascular diseases, stroke and several malignant diseases [1]. Figure 1. Global cigarette consumption. Increasing trend in the consumption of cigarettes (1880-2000)*. *Modified from Mackay, J.; Eriksen, M. The Tobacco Atlas © World Health Organization Publications. Chronic obstructive pulmonary disease (COPD) is a major and growing cause of morbidity and mortality in countries at all levels of economic development [2, 3] with smoking being recognized as its most important causative factor [1, 3]. According to the WHO estimates, 80 million people in the world have moderate to severe COPD. More than 3 million people died of COPD in 2005, which corresponds to 5% of all adult deaths globally and it is estimated that by 2020 it will become the third leading cause of death worldwide [4]; this chronic disease is however, barely even acknowledged in the health statistics of many countries. Many patients remain undiagnosed, experience high levels of symptoms, their quality of life is often poor and they usually die prematurely of it or its complications [5-8]. Although cigarette smoking is the most commonly encountered tobacco-related risk factor for COPD [4], other types of tobacco smoking popular in various countries are also risk factors for COPD [9, 10] and air pollution resulting from the burning of wood and other biomass fuels, has also been identified as a COPD risk factor [4]. Passive exposure to cigarette smoke may also contribute to the development of COPD by increasing the lung total burden of inhaled particles and gases [11]. There is now evidence that most smokers develop some respiratory impairment due to COPD [12, 13]. One recent study addressing this issue [14] reported that 50% of smokers eventually develop COPD, as defined according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD)