The threat posed by smoking to global health is unprecedented, but so is the potential for reducing smoking-related mortality with cost-effective policies. — Curbing the Epidemic: Governments and the Economics of Tobacco Control. Washington: World Bank; 1999.
Figure 1. Image from an Australian anti-smoking campaign. Photo by: Action on Smoking and Health Australia
Use of tobacco is the second-leading cause of death in the world. It is responsible for 1 in 10 adult deaths, or more than 4.9 million deaths each year.1 If current smoking trends continue, it will kill 10 million people each year by 2020.2 Around the world, there are currently about 1.3 billion smokers; 84% of these live within developing and transitional economies.1 Tobacco is estimated to cost governments US$200 billion per year through direct health care costs and loss of productivity from death and illness; a third of these costs are borne by developing countries.2 In poor households, tobacco costs may constitute up to 10% of their total yearly household expenditure.1,2
Worldwide, people from lower socioeconomic groups, those with poor mental health (especially depression) and men and boys are 4 times more likely to smoke.3 Changes in smoking trends are, however, evident: the Global Youth Tobacco Survey showed that young girls were smoking almost as much as men,1,3 and increased smoking uptake attributed to greater female autonomy and altered work roles is predicted to take place in developing countries.3
Sex-related differences in response to tobacco (e.g., women find it harder to quit smoking and are more likely to develop aggressive lung cancer at lower levels of smoking) may also result in increased future deaths. Projections for future tobacco-related deaths are, therefore, likely underestimated.
Figure 2. Another graphic illustration from an Australian anti-smoking campaign. Photo by: Action on Smoking and Health Australia
Increased global smoking rates have resulted from many factors, such as trade liberalization; direct foreign investment; global marketing; transnational tobacco advertising, promotion and sponsorship; and international tobacco smuggling (for more detail, see www.who.int/tobacco/framework/background/en [accessed 2005 Dec. 15]). Reductions in tariff and nontariff trade barriers to tobacco and tobacco products have decreased tobacco prices and enabled poorer individuals to start smoking.
A concerted global effort is being directed at measures that reduce smoking uptake rates, encourage individuals to quit smoking, prevent opportunities for second-hand smoke inhalation, and control tobacco advertising and sales. Some of these measures create a dilemma for governments, which receive considerable income from sales taxes from cigarette products. It seems, however, that it is possible to have your cake and eat it too: the World Bank estimates that a 10% increase in tobacco prices would cause a 8% reduction in demand in low-income countries without a reduction in tax revenue.1 Increasing prices for tobacco has been shown to be the most cost-effective tobacco control measure.1
The World Health Organization (WHO) Framework Convention on Tobacco Control (WFCTC) is also gaining momentum as the world's first public health treaty (Box 1). The treaty is a binding legal instrument that addresses issues of both supply and demand related to tobacco use and control. Key elements of the treaty include restrictions on tobacco advertising, sponsorship and promotion; improved packaging and labelling of tobacco products (at least 30% of package display areas must contain clear health warnings); improved indoor clean-air controls; and strengthened legislation to cut down smuggling of tobacco. It also encourages agricultural diversification and promotion of alternative livelihoods for tobacco farmers, to reduce supply. Uniquely, the treaty encourages parties to ensure that their national laws are in line with WFCTC requirements and to work together on criminal and civil liability issues for tobacco control.
China, Brazil, India and the United States together account for two-thirds of global tobacco production. China, Brazil and India have all signed and ratified the treaty; the United States (the third-largest global exporter) has signed the treaty but not ratified it, and is therefore not legally bound to adhere to it. Other progress is evident: since signing the treaty, Tanzania has introduced a ban on smoking in public places and the Democratic People's Republic of Korea has announced that it will double the price of cigarettes in order to reduce consumption (see www.who.int/features/2003/08/en).
In addition, many country and community level initiatives encourage reduced tobacco use (Box 2, Box 3). The Global Tobacco Surveillance system has been set up by the US Centers for Disease Control and Prevention and WHO to provide data on prevalence, attitude, morbidity and mortality related to tobacco use and information on programs and policies to control it.
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