How to reduce adolescent smoking in low-income and middle-income countries
Authors: David P Thomas, Marita Hefler
Journal: The Lancet Global Health (2016)

Based on current trends, smoking is predicted to cause 1 billion deaths in the 21st century.1Jha P Avoidable global cancer deaths and total deaths from smoking.Nat Rev Cancer. 2009; 9: 655-664Crossref PubMed Scopus (370) Google Scholar Nevertheless, there are signs of hope. Although the number of smokers has increased worldwide due to population growth, daily smoking prevalence among men fell from 41% in 1980 to 31% in 2012, and from 11% to 6% in women in the same time.2Ng M Freeman MK Fleming TD et al.Smoking prevalence and cigarette consumption in 187 countries, 1980-2012.JAMA. 2014; 311: 183-192Crossref PubMed Scopus (1108) Google Scholar 52 years since the first US Surgeon General's report on smoking and health, the academic and policy debate is increasingly about the most efficient strategies for the tobacco endgame and a world where less than 5% of the adult population use tobacco.3Beaglehole R Bonita R Yach D Mackay J Reddy KS A tobacco-free world: a call to action to phase out the sale of tobacco products by 2040.Lancet. 2015; 385: 1011-1018Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar The tobacco epidemic is moving from high-income countries to low-income and middle-income countries (LMICs).4Mathers CD Loncar D Projections of global mortality and burden of disease from 2002 to 2030.PLoS Med. 2006; 3: e442Crossref PubMed Scopus (7521) Google Scholar To achieve global tobacco use prevalence of less than 5%, a sustained focus in these countries is required. Tobacco deaths are declining in high-income countries; by 2030, 6·8 million of the projected 8·3 million annual global tobacco deaths will be in LMICs, where tobacco deaths are expected to double between 2002 and 2030.4Mathers CD Loncar D Projections of global mortality and burden of disease from 2002 to 2030.PLoS Med. 2006; 3: e442Crossref PubMed Scopus (7521) Google Scholar The tobacco industry needs to keep recruiting young smokers to replace these smokers who are dying. In The Lancet Global Health, Bo Xi and colleagues5Xi B Liang Y Liu Y et al.Tobacco use and second-hand smoke exposure in young adolescents aged 12–15 years: data from 68 low-income and middle-income countries.Lancet Glob Health. 2016; (published online Sept 30.)http://dx.doi.org/10.1016/S2214-109X(16)30187-5Summary Full Text Full Text PDF PubMed Scopus (121) Google Scholar describe tobacco use and secondhand smoke exposure in young adolescents in 68 LMICs. Monitoring of progress by use of surveys such as the Global School-based Health Survey (GSHS) and the Global Tobacco Youth Survey (GYTS) is essential to understand whether current policies are working, especially in LMICs where data are more limited. Unfortunately, Xi and colleagues cannot neatly compare their new global and regional estimates for LMICs with earlier published estimates due to their use of different countries, different age groups, and different questions.6Warren CW Jones NR Eriksen MP Asma S for the Global Tobacco Surveillance System collaborative groupPatterns of global tobacco use in young people and implications for future chronic disease burden in adults.Lancet. 2006; 367: 749-753Summary Full Text Full Text PDF PubMed Scopus (370) Google Scholar, 7Page RM Danielson M Multi-country, cross-national comparison of youth tobacco use: findings from global school-based health surveys.Addict Behav. 2011; 36: 470-478Crossref PubMed Scopus (38) Google Scholar The results are more useful at a national level, where data can be used to improve national policy. As with much tobacco use data, the results demonstrate enormous variation between countries, even within the same region. These differences can provide important lessons about tobacco control success and failure. For example, Xi and colleagues highlight the very high adolescent smoking prevalence and prevalence of exposure to secondhand smoke in the small Pacific island nation of Kiribati. However, national data can hide variations in smoking prevalence within countries due to important social determinants such as education levels, wealth, and gender.8Hosseinpoor AR Parker LA Tursan d'Espaignet E Chatterji S Social determinants of smoking in low- and middle-income countries: results from the World Health Survey.PloS one. 2011; 6: e20331Crossref PubMed Scopus (84) Google Scholar Research about these subnational differences in smoking in LMICs is also important to inform policy. Perhaps counter-intuitively, the most strategic tobacco control policies to reduce adolescent smoking and secondhand smoke exposure in LMICs may not be those targeting adolescents. Targeted campaigns can be expensive, and are unlikely to be as effective as the more affordable tobacco control policies in the WHO Framework Convention on Tobacco Control, and its MPOWER package of policies.9World Health OrganizationWHO Report on the Global Tobacco Epidemic, 2008: The MPOWER package. WHO, Geneva2008Crossref Google Scholar For example, raising tobacco taxes can lead to rapid decreases in tobacco consumption, has a greater impact on younger than older smokers, is achievable in LMICs, and leads to increased government revenue for other tobacco control policies.10Jha P Peto R Global effects of smoking, of quitting, and of taxing tobacco.N Engl J Med. 2014; 370: 60-68Crossref PubMed Scopus (493) Google Scholar Adolescents will also benefit from LMICs banning tobacco advertising and promotion, and introducing regulations to protect non-smokers from secondhand smoke. Because the current and future profitability of transnational tobacco companies is reliant on smoking increasing in LMICs, these companies continue to target children in their marketing and promotion of tobacco. They use their considerable political influence to consistently oppose the introduction of evidence-based tobacco control policies in LMICs, and undermine these policies when introduced.11Gilmore AB Fooks G Drope J Bialous SA Jackson RR Exposing and addressing tobacco industry conduct in low-income and middle-income countries.Lancet. 2015; 385: 1029-1043Summary Full Text Full Text PDF PubMed Scopus (208) Google Scholar Without exposing and combating the influence of these tobacco companies, we will not be able to effectively reduce adolescent smoking or deaths from smoking in LMICs. We declare no competing interests. Tobacco use and second-hand smoke exposure in young adolescents aged 12–15 years: data from 68 low-income and middle-income countriesTobacco use and second-hand smoke exposure were frequent among young adolescents aged 12–15 years in low-income and middle-income countries. Parental tobacco use and second-hand smoke exposure were strongly associated with young adolescents' tobacco use. The data emphasise the need to strengthen tobacco control interventions and programmes in young adolescents from low-income and middle-income countries. Full-Text PDF Open AccessReducing adolescent smoking in IndiaDavid P Thomas and Marita Hefler1 suggest ways to reduce adolescent smoking in low-income and middle-income countries, in response to the Article by Bo Xi and colleagues (November, 2016).2 We suggest some additional measures to reduce adolescent smoking in India. Full-Text PDF Open Access