How to prevent 100 million deaths from tobacco

Abstract

For the fi rst time ever, the world’s leading agent of death is a man-made substance—tobacco. If current trends continue, tobacco will kill 1000 million people prematurely during this century. Tobacco, which kills at least a third of people who use it, is also the largest single cause of health inequalities in some low-income populations. Millions of deaths can be prevented if we take urgent action based on available information. Despite this enormous and growing burden of premature illness and death, and despite evidence showing the eff ectiveness of antitobacco initiatives, few countries use most of these public-health interventions to reduce tobacco use and none use them all. Although the framework convention on tobacco control (FCTC) provides context for improvement, there is currently no standard technical package for tobacco control analogous to those developed and implemented for control of tuberculosis, HIV, or malaria. Furthermore, no quantifi able international target for tobacco control exists, and government resources and bilateral or private-sector funding are limited. Here, we propose a global target, outline a technical package, and describe a new grant programme to expand implementation of eff ective tobacco control. Although global data are emerging for youth smoking, data for prevalence of adult smoking are non-standardised and of uneven quality. An estimated two-thirds of the world’s more than 1000 million adult smokers live in 15 low-income or middle-income nations, and 80% of the world’s smokers live in 24 countries. Because quantifi cation of illness caused by tobacco can be diffi cult, particularly in developing countries, the proportion of the adult population that smokes is the most important global target for tobacco control. Current global prevalence of smoking in adults is estimated at about 25%. Some developed and less-developed countries (eg, Australia, Brazil, Canada, South Africa, and Sweden) have reduced this rate to 20% or lower by implementation of eff ective policies; all nations and populations should be able to achieve this prevalence level. Simply put, and for discussion reasons, the goal would be for no nation to have a smoking rate of more than 20% and for countries to reduce the absolute smoking prevalence by at least 5% (or to decrease prevalence if already 5–10% and maintain prevalence at <5% if it was at this level at the outset) between 2005 and 2020. Keeping rates low is especially important for the large population of young women in Asia and elsewhere who do not currently smoke but are targeted by the tobacco industry. Of course, these targets would need to be reviewed and agreed by countries and global authorities. If the world reduces absolute adult smoking prevalence by 5% by 2020, at least 100 million fewer tobacco-related premature deaths would occur in people alive today, and another 50 million deaths would be prevented in infants born between now and 2030 (table 1). Virtually all deaths prevented up to 2050 would be of current smokers who quit; subsequently, prevented deaths would increasingly be of people who never start smoking. Population dynamics might limit the potential to reduce prevalence rapidly; whether this specifi c goal can be reached is not known. However, we do know that eff ective strategies to reduce smoking exist—and they are not being applied widely. Tobacco use can be decreased by addressing price, image, exposure, cessation experience, and monitoring (table 2). In New York City, a comprehensive tobacco-control programme was implemented in 2002. Tax increases raised the legal retail price of cigarettes by 32% to nearly US$7 per pack. Virtually all indoor workplaces, including bars and restaurants, were made smoke-free, despite vocal opposition. Hard-hitting print and broadcast antitobacco advertising campaigns were initiated (in the USA, state and local restrictions on tobacco company marketing are currently pre-empted by federal legislation). Smokers were provided with free courses of nicotine-replacement treatment to help them quit; nearly 20% of smokers were reached over 3 years. Rigorous surveillance was established. After a decade with no change in smoking prevalence, within 2 years there were nearly 200 000 fewer smokers in New York—a decline in adult smoking prevalence from 21·6% to 18·4%. Progress on this scale faces political obstacles: although tobacco taxation is favoured by most of the public, smoke-free policies and other measures are usually controversial when introduced, and eff ective tobacco-control measures are almost invariably opposed by the powerful tobacco industry. Nonetheless, antismoking measures, once implemented, are generally popular and well-accepted. Lancet 2007; 369: 1758–61