Smoking tobacco, the major cause of death and disability in Cuba
Authors: Pedro Ordunez, Norm RC Campbell
Journal: The Lancet Global Health (2020)

In 2015, about a quarter of the global population, aged 15 years or older, were current users of some form of tobacco. The downward trend in the prevalence of tobacco use is projected to continue from 33·3% in 2000 to 20·9% by 2025, if the existing pace of tobacco control is maintained.1WHOWHO global report on trends in prevalence of tobacco smoking 2000–2025, third edition.https://apps.who.int/iris/bitstream/handle/10665/330221/9789240000032-eng.pdf?ua=1Date: 2019Date accessed: April 26, 2020Google Scholar Despite this progress, the number of people dying from a tobacco-related illness was estimated to be more than 8·1 million in 2017.2Institute for Health Metrics and EvaluationGlobal Health Data Exchange.http://ghdx.healthdata.org/gbd-results-toolDate accessed: April 26, 2020Google Scholar Smoking also causes a heavy economic burden, especially for developing countries.3Goodchild M Nargis N Tursan d'Espaignet E Global economic cost of smoking-attributable diseases.Tob Control. 2018; 27: 58-64Crossref PubMed Scopus (263) Google Scholar To reduce the threat to human development, the UN Sustainable Development Goals4UNSustainable Development Goal 3—ensure healthy lives and promote well-being for all at all ages. Progress of Goal 3 in 2019.https://sustainabledevelopment.un.org/sdg3Date accessed: April 26, 2020Google Scholar included "strengthening the implementation of the WHO Framework Convention on Tobacco Control (FCTC)",5WHOWHO Framework Convention on tobacco control. World Health Organization, Geneva2005Google Scholar a global commitment to reverse the tobacco epidemic. In The Lancet Global Health, Blake Thomson and colleagues6Thomson B Armas Rojas N Lacey B et al.Association of childhood smoking and adult mortality: prospective study of 120 000 Cuban adults.Lancet Glob Health. 2020; 8: e850-e859Summary Full Text Full Text PDF Scopus (22) Google Scholar provide another remarkable research advancement from the Cuba Prospective Study. This cohort study recruited adults aged 30 years or older from the general population in Cuba between Jan 1, 1996, and Nov 24, 2002, and was established primarily to investigate the effects of tobacco on premature death in Cuba. Participants were assessed and followed up for cause-specific mortality. After nearly 20 years of follow-up (until 2017), over 30 000 participants had died, including about 14 000 cardiovascular deaths and 7000 cancer deaths.7Armas Rojas N Lacey B Lewington S et al.Cohort profile: the Cuba Prospective Study.Int J Epidemiol. 2019; 48 (81e): 680Crossref PubMed Scopus (5) Google Scholar Among the 118 840 participants6Thomson B Armas Rojas N Lacey B et al.Association of childhood smoking and adult mortality: prospective study of 120 000 Cuban adults.Lancet Glob Health. 2020; 8: e850-e859Summary Full Text Full Text PDF Scopus (22) Google Scholar aged 30–69 years at recruitment, 27 264 (52%) of 52 524 men and 19 313 (29%) of 66 316 women were current smokers. About a third of current cigarette smokers reported having started before age 15 years (1724 [4%] of 44 042 at ages 5–9 years, and 13 432 [31%] at ages 10–14 years). Smoking cessation was uncommon, with only 12% of men and 15% of women having quit at baseline. Compared with never-smokers, participants who had started smoking at ages 5–9 years had the highest all-cause mortality rate ratio (2·51, 95% CI 2·21–2·85), followed by ages 10–14 years (1·83, 1·72–1·95), 15–19 years (1·56, 1·46–1·65), and ages 20 years or older (1·50, 1·39–1·62). Ultimately, smoking accounted for a quarter of all premature deaths in this cohort population. In 2017, the age-standardised prevalence of current tobacco use among people aged 15 years or older in Cuba was 27·1% (39·7% for males, 14·5% for females).2Institute for Health Metrics and EvaluationGlobal Health Data Exchange.http://ghdx.healthdata.org/gbd-results-toolDate accessed: April 26, 2020Google Scholar Smoking cigarettes accounted for the most death and disability combined in this population, followed by high systolic blood pressure and a high body-mass index. 22% of deaths due to ischaemic heart diseases and 16% of stroke deaths (the two leading causes of death) can be attributed to tobacco use, and 75% of lung cancer and 55% of chronic respiratory disease deaths can also be attributed to tobacco.2Institute for Health Metrics and EvaluationGlobal Health Data Exchange.http://ghdx.healthdata.org/gbd-results-toolDate accessed: April 26, 2020Google Scholar The study by Thomson and colleagues,6Thomson B Armas Rojas N Lacey B et al.Association of childhood smoking and adult mortality: prospective study of 120 000 Cuban adults.Lancet Glob Health. 2020; 8: e850-e859Summary Full Text Full Text PDF Scopus (22) Google Scholar done in a upper-middle-income country, is a substantive advancement. Harm from smoking in young children was well established; however, the quantification of the effects of regularly smoking from early childhood on premature death had not been well described. In this cohort study, having started smoking in very early childhood (ie, age 5–9 years) was associated with nearly 3 times the excess risk compared with starting at age 15 years or older. The study also found that the association between childhood smoking and mortality was almost completely attenuated in participants who quit smoking before age 40 years. The Cuba Prospective Study 6Thomson B Armas Rojas N Lacey B et al.Association of childhood smoking and adult mortality: prospective study of 120 000 Cuban adults.Lancet Glob Health. 2020; 8: e850-e859Summary Full Text Full Text PDF Scopus (22) Google Scholar has many strengths. The high response rate and the large sample size allowed assessing the risks of smoking and the benefits of quitting in a population where smoking in early childhood was common. Thomson and colleagues noted that one noteworthy limitation is that the study was done during the Special Period of economic deprivation in Cuba (early 1990s), which temporarily altered smoking patterns. During this period, the number of cigarettes smoked per day was reduced, but the prevalence of smokers was not. Similarly, the years at the end of the crisis (1997–2000) and postcrisis years (2001–02) were characterised by substantial declines in average bodyweight, coronary heart disease, and all-cause mortality of the population. 6 years afterwards, the situation was reverted to precrisis levels, including the population tobacco consumption pattern and mortality due to cardiovascular disease and diabetes.8Franco M Bilal U Orduñez P et al.Population-wide weight loss and regain in relation to diabetes burden and cardiovascular mortality in Cuba 1980–2010: repeated cross sectional surveys and ecological comparison of secular trends.BMJ. 2013; 346f1515Crossref PubMed Scopus (118) Google Scholar Health care in Cuba, beyond ideological controversies, is a global icon. The island bet its political—and economic—capital on universal access to health care more than 60 years ago. Cuba has a very strong health-care infrastructure capable of producing high-quality medicines and technologies, an extensive primary health-care network, and a very large workforce.9Cooper RS Kennelly JF Ordunez-Garcia P Health in Cuba.Int J Epidemiol. 2006; 35: 817-824Crossref PubMed Scopus (121) Google Scholar Likewise, Cuba's role in global health diplomacy and its overall performance, measured in terms of health indicators, are disproportionately better than its limited economic resources would indicate (appendix). With such a history of health successes and a free compulsory universal education system for children and adolescents, Cuba's performance in the fight against tobacco10WHOWHO Report on the global tobacco epidemic, 2019. World Health Organization, Geneva2019Google Scholar deserves a more strategic analysis by the Cuban authorities. The full implementation of the FCTC, including the MPOWER measures, as has been happening in other countries, could help to reduce the tobacco prevalence rates by lowering initiation rates and encouraging quit rates among users. On the basis of very strong existing evidence that tobacco use is deteriorating the health of Cubans and exhausting their limited resources, Cuba has a new opportunity to unfold the full potential of its health system. We declare no competing interests. PO is a staff member of the Pan American Health Organization. The author alone is responsible for the views expressed in this publication, and they do not necessarily represent those of the Pan American Health Organization. We want to pay a tribute of remembrance to the recently deceased Professor Alfredo Dueñas Herrera (senior author of the Cuban Prospective Study), pioneer of preventive cardiology, and champion of the fight against tobacco in Cuba. Download .pdf (.2 MB) Help with pdf files Supplementary appendix COVID-19 and risks to the supply and quality of tests, drugs, and vaccinesEmergency efforts are underway to find optimum medical products to prevent infection and diagnose and treat patients during the coronavirus disease 2019 (COVID-19) pandemic. Production and supply chains for COVID-19 candidate drugs (such as chloroquine and hydroxychloroquine), and for many other essential medical products, are being impaired by this crisis.1 Supply chains for vital drugs for other diseases (such as systemic lupus erythematosus) are being disrupted because they are being repurposed to use against COVID-19, without adequate supporting evidence. Full-Text PDF Open Access