Spatial, Temporal, and Demographic Patterns in Prevalence of Smoking Tobacco Use and Attributable Disease Burden in 204 Countries and Territories, 1990–2019: A Systematic Analysis from the Global Burden of Disease Study 2019

Background: Ending the global tobacco epidemic is a defining challenge in global health. Timely and comprehensive estimates of the prevalence of smoking tobacco use and attributable disease burden are needed to guide tobacco control efforts nationally and globally. Methods: We estimated the prevalence of smoking tobacco use and attributable disease burden for 204 countries and territories, by age and sex, from 1990 to 2019 as part of the Global Burden of Diseases, Injuries, and Risk Factors Study. We modelled multiple smoking-related indicators from 3625 nationally representative surveys. We completed systematic reviews and did Bayesian meta-regressions for 36 causally linked health outcomes to estimate non-linear dose-response risk curves for current and former smokers. We used a direct estimation approach to estimate attributable burden, providing more comprehensive estimates of the health effects of smoking than previously available. Findings: Globally in 2019, 1·14 billion (95% uncertainty interval 1·13–1·16) individuals were current smokers, who consumed 7·41 trillion (7·11–7·74) cigarette-equivalents of tobacco in 2019. Although prevalence of smoking had decreased significantly since 1990 among both males (27·5% [26·5–28·5] reduction) and females (37·7% [35·4–39·9] reduction) aged 15 years and older, population growth has led to a significant increase in the total number of smokers from 0·99 billion (0·98–1·00) in 1990. Globally in 2019, smoking tobacco use accounted for 7·69 million (7·16–8·20) deaths and 200 million (185–214) disability-adjusted life-years, and was the leading risk factor for death among males (20·2% [19·3–21·1] of male deaths). 6·68 million [86·9%] of 7·69 million deaths attributable to smoking tobacco use were among current smokers. Interpretation: In the absence of intervention, the annual toll of 7·69 million deaths and 200 million disability-adjusted life-years attributable to smoking will increase over the coming decades. Substantial progress in reducing the prevalence of smoking tobacco use has been observed in countries from all regions and at all stages of development, but a large implementation gap remains for tobacco control. Countries have a clear and urgent opportunity to pass strong, evidencebased policies to accelerate reductions in the prevalence of smoking and reap massive health benefits for their citizens. Funding Information: Bloomberg Philanthropies and the Bill & Melinda Gates Foundation. Declaration of Interests: ViA reports personal fees from Bayer Healthcare, Boehringer Ingelheim/Lilly alliance, Bristol Myers Squibb/Pfizer alliance, and Novo Nordisk outside of the submitted work. RA reports consultancy and speakers' fees from UCB, Sandoz, AbbVie, Zentiva, Teva, Laropharm, CEGEDIM, Angelini, Biessen Pharma, Hofigal, AstraZeneca, and Stada outside of the submitted work. BeA reports personal fees from Australian Institute of Sports; non-financial support from Zydus Cadila; and grants and non-financial support from Natural Remedies outside of the submitted work. FG was employed by Public Health England during the conduct of the study, which does not necessarily endorse this study. GJH reports personal fees from the American Heart Association outside of the submitted work. SMSI reports grants from National Heart Foundation of Australia and from the Australian National Health and Medical Research Council (NHMRC) outside of the submitted work. SVK reports grants from Chief Scientist Office and UK Medical Research Council during the conduct of the study. KK reports non-financial support from UGC Centre of Advanced Study (CAS II), Department of Anthropology, Panjab University, Chandigarh, India, outside of the submitted work. StL reports personal fees from Akcea Therapeutics, Amedes, AMGEN, Berlin-Chemie, Boehringer Ingelheim Pharma, Daiichi Sankyo, Lilly, MSD Sharp & Dohme, Novo Nordisk, Sanofi-Aventis, Synlab, Unilever, and Upfield, and non-financial support from Preventicus outside of the submitted work. WM is Program Analyst in Population and Development at the UN Population Fund-UNFPA Country Office in Peru, which does not necessarily endorse this study. TRM reports contracts from Gov’t Plaintiff Lawyers, JUUL, outside of the submitted work. BoN reports personal fees from AstraZeneca and Bayer, outside of the submitted work. SimS reports grants, personal fees, and non-financial support from Abbott and Novartis; personal fees and non-financial support from Allergan-Abbvie, AstraZeneca, and Teva; and personal fees from Eli Lilly and Novo Nordisk outside of the submitted work. AES reports personal fees from Takeda, Novartis, Servier, and Omron Healthcare outside of the submitted work. JAS reports consultancy fees from Crealta/Horizon, Medisys, Fidia, Two Labs Inc, Adept Field Solutions, Clinical Care options, Clearview Healthcare Partners, Putnam Associates, Focus Forward, Navigant Consulting, Spherix, MedIQ, UBM, Trio Health, Medscape, WebMD, Practice Point communications, the National Institutes of Health, and the American College of Rheumatology; payment for lectures including service on Simply Speaking speaker’s bureau; and stock ownership in TPT Global Tech, Vaxart pharmaceuticals, and Charlotte’s Web Holdings. JAS previously owned stock options in Amarin, Viking, and Moderna pharmaceuticals; held placement on the steering committee of OMERACT, an international organisation that develops measures for clinical trials and receives arm’s length funding from 12 pharmaceutical companies; serves on the US Food and Drug Administration Arthritis Advisory Committee; is a member of the Veterans Affairs Rheumatology Field Advisory Committee; and is the editor and the director of the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis. DJS reports personal fees from Lundbeck, Takeda, Johnson & Johnson, and Servier outside of the submitted work. StS reports grants from Edwards Lifesciences, Medtronic, Boston Scientific, and Abbott; and personal fees from Boston Scientific, Teleflex, and BTG outside of the submitted work. JS reports ownership in companies providing services to Itrim, Amgen, Janssen, Novo Nordisk, Eli Lilly, Boehringer, Bayer, Pfizer, and AstraZeneca outside of the submitted work. FT reports grants and personal fees from Novartis, Thea, Alcon, Pfizer, and Bayer; grants from Bausch & Lomb; and personal fees from Allergan, Omikron, and Santen outside of the submitted work. All other authors declare no competing interests.