Death, disease, and tobacco
Authors: John Britton
Journal: The Lancet (2017)

Throughout history, humanity has been blighted by epidemics of communicable diseases that medical science and public policy have, to varying degrees, been able to control. Sanitation, immunisation, mosquito nets, and antimicrobial agents are examples of developments that have helped to generate substantial reductions in incidence of and mortality from cholera, dysentery, smallpox, measles, HIV, tuberculosis, and many other infectious diseases. Similar success is now urgently required to halt the global spread of non-communicable diseases that have dominated health in high-income countries for the past century, and are now emerging as major disease burdens in low-income and middle-income countries.1GBD 2015 DALYs and HALE CollaboratorsGlobal, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015.The Lancet. 2016; 388: 1603-1658Summary Full Text Full Text PDF PubMed Scopus (1440) Google Scholar This is especially true of the epidemics of lung cancer, chronic obstructive pulmonary disease (COPD), cardiovascular disease, and other disorders that are caused by tobacco smoking. A new report in The Lancet using data from the Global Burden of Disease Study adds quantitative detail to an already extensive international literature on the health impact of the global tobacco epidemic by providing comprehensive estimates of death and disability caused by smoking at the country level.2GBD 2015 Tobacco CollaboratorsSmoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015. Lancet.http://dx.doi.org/10.1016/S0140-6736(17)30819-XDate: 2017Google Scholar The findings are sobering. In 2015, smoking caused more than one in ten deaths worldwide, killing more than 6 million people with a global loss of nearly 150 million disability-adjusted life-years.2GBD 2015 Tobacco CollaboratorsSmoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015. Lancet.http://dx.doi.org/10.1016/S0140-6736(17)30819-XDate: 2017Google Scholar Smoking prevalence and consequent morbidity and mortality are now falling in most (but not all) rich countries, but future mortality in low-income and middle-income countries is likely to be huge. Worldwide, one in four men, and a total of 933 million people, are estimated to be current daily smokers,2GBD 2015 Tobacco CollaboratorsSmoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015. Lancet.http://dx.doi.org/10.1016/S0140-6736(17)30819-XDate: 2017Google Scholar and 80% of these smokers live in low-income and middle-income countries.3WHOTobacco fact sheet. World Health Organization, Geneva2016http://www.who.int/mediacentre/factsheets/fs339/en/Google Scholar Half of these, or half a billion people alive today, can be expected to be killed prematurely by their smoking unless they quit.3WHOTobacco fact sheet. World Health Organization, Geneva2016http://www.who.int/mediacentre/factsheets/fs339/en/Google Scholar At present, smoking prevalence is still low in countries with a low socio-demographic index,2GBD 2015 Tobacco CollaboratorsSmoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015. Lancet.http://dx.doi.org/10.1016/S0140-6736(17)30819-XDate: 2017Google Scholar, 4Ng M Freeman MK Fleming TD et al.Smoking prevalence and cigarette consumption in 187 countries, 1980–2012.JAMA. 2014; 311: 183-192Crossref PubMed Scopus (1114) Google Scholar but, on past experience in richer countries, it is only a matter of time before men and then women in all countries take up smoking, and in due course die from lung cancer, COPD, and other diseases caused by smoking, as has happened in the richer world.5Lopez AD Collishaw NE Piha T A descriptive model of the cigarette epidemic in developed countries.Tob Control. 1994; 3: 242-247Crossref Google Scholar Even though the prevalence of smoking is decreasing in many low-income and middle-income countries, including many of those with the most smokers (eg, China and India), population growth means that the number of smokers, and hence the burden of harm from smoking, continues to rise.2GBD 2015 Tobacco CollaboratorsSmoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015. Lancet.http://dx.doi.org/10.1016/S0140-6736(17)30819-XDate: 2017Google Scholar, 4Ng M Freeman MK Fleming TD et al.Smoking prevalence and cigarette consumption in 187 countries, 1980–2012.JAMA. 2014; 311: 183-192Crossref PubMed Scopus (1114) Google Scholar Responsibility for this global health disaster lies mainly with the transnational tobacco companies, which clearly hold the value of human life in very different regard to most of the rest of humanity. For example, the latest annual report from British American Tobacco (BAT),6British American TobaccoDelivering today, investing in tomorrow.http://www.bat.com/group/sites/uk__9d9kcy.nsf/vwPagesWebLive/DO9DCL3B/$FILE/medMDAKAJCS.pdf?openelementDate: 2017Google Scholar historically the most global of today's five transnational companies,7Callard C Follow the money: how the billions of dollars that flow from smokers in poor nations to companies in rich nations greatly exceed funding for global tobacco control and what might be done about it.Tob Control. 2010; 19: 285-290Crossref PubMed Scopus (32) Google Scholar details with apparent pride their geographical diversity, strong earnings and market share growth, market leadership in more than 55 countries, and manufacturing facilities in 42 of them.6British American TobaccoDelivering today, investing in tomorrow.http://www.bat.com/group/sites/uk__9d9kcy.nsf/vwPagesWebLive/DO9DCL3B/$FILE/medMDAKAJCS.pdf?openelementDate: 2017Google Scholar In 2016, BAT sold 665 billion cigarettes, making £5·2 billion in profit; and recorded rising profits across most of the world.6British American TobaccoDelivering today, investing in tomorrow.http://www.bat.com/group/sites/uk__9d9kcy.nsf/vwPagesWebLive/DO9DCL3B/$FILE/medMDAKAJCS.pdf?openelementDate: 2017Google Scholar Countering the heft and influence of commercial behemoths such as this demands human resources, governance, expertise, and financial backing that few rich countries have yet to fully establish, let alone those countries at the lower end of the development spectrum. The WHO Framework Convention Alliance provides detailed guidance to support implementation of a growing range of effective tobacco control policies, including taxation, advertising bans, smoke-free policies, and protection against the vested interests of the tobacco industry,8WHOFramework Convention on Tobacco Control Adopted Guidelines. World Health Organization, Geneva2017http://www.who.int/fctc/treaty_instruments/adopted/en/Google Scholar but, in most parts of the world, translating this guidance into effective legislation has a long way to go.9WHOWHO report on the global tobacco epidemic, 2015. Raising taxes on tobacco. World Health Organization, Geneva2015http://apps.who.int/iris/bitstream/10665/178574/1/9789240694606_eng.pdf?ua=1&ua=1Google Scholar Like in many rich countries, tobacco control legislation too often becomes mired in procedure and delayed or otherwise undermined by tobacco industry misrepresentation of science, fearmongering over tax revenue and illicit supply, corporate social responsibility activities, offers of help drafting tobacco laws, threatened or real legal action, and, in some countries, economic dependence on tobacco growing, and conflicts of interest.10Balwicki Ł Stokłosa M Balwicka-Szczyrba M Tomczak W Tobacco industry interference with tobacco control policies in Poland: legal aspects and industry practices.Tob Control. 2016; 25: 521-526Crossref PubMed Scopus (22) Google Scholar, 11Crosbie E Sebrie EM Glantz SA Tobacco industry success in Costa Rica: the importance of FCTC article 5.3.Salud Publica Mex. 2012; 54: 28-38Crossref PubMed Google Scholar, 12Lencucha R Drope J Labonte R Zulu R Goma F Investment incentives and the implementation of the Framework Convention on Tobacco Control: evidence from Zambia.Tob Control. 2016; 25: 483-487Crossref PubMed Scopus (32) Google Scholar, 13Tam J van Walbeek C Tobacco control in Namibia: the importance of government capacity, media coverage and industry interference.Tob Control. 2014; 23: 518-523Crossref PubMed Scopus (16) Google Scholar, 14Rao NV Bhojani U Shekar P Daddi S Conflicts of interest in tobacco control in India: an exploratory study.Tob Control. 2016; 25: 715-718Crossref PubMed Scopus (13) Google Scholar The persistence of smoking in the countries first affected by the tobacco epidemic2GBD 2015 Tobacco CollaboratorsSmoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015. Lancet.http://dx.doi.org/10.1016/S0140-6736(17)30819-XDate: 2017Google Scholar reflects decades of failure first to recognise smoking as a health problem, and second to take decisive action to implement the policies currently promoted by the WHO Framework Convention on Tobacco Control, but articulated long ago in the Royal College of Physicians' report of 1962.15Royal College of PhysiciansSmoking and health. A report on smoking in relation to lung cancer and other diseases. Royal College of Physicians, London1962https://www.rcplondon.ac.uk/projects/outputs/smoking-and-health-1962Google Scholar Today, the smoking epidemic is being exported from the rich world to low-income and middle-income countries, slipping under the radar while apparently more immediate priorities occupy and absorb scarce available human and financial resources. The epidemic of tobacco deaths will progress inexorably throughout the world until and unless tobacco control is recognised as an immediate priority for development, investment, and research. Rich-world experience also teaches that where the tobacco industry leads and succeeds today, so the alcohol and food industries follow tomorrow.16Moodie R Stuckler D Monteiro C et al.Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries.Lancet. 2013; 381: 670-679Summary Full Text Full Text PDF PubMed Scopus (1009) Google Scholar I declare no competing interests. Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015The pace of progress in reducing smoking prevalence has been heterogeneous across geographies, development status, and sex, and as highlighted by more recent trends, maintaining past rates of decline should not be taken for granted, especially in women and in low-SDI to middle-SDI countries. Beyond the effect of the tobacco industry and societal mores, a crucial challenge facing tobacco control initiatives is that demographic forces are poised to heighten smoking's global toll, unless progress in preventing initiation and promoting cessation can be substantially accelerated. Full-Text PDF Open Access