Tobacco: more than 8 million deaths per year

Tobacco is a major cause of death, disease and impoverishment

The tobacco epidemic is one of the most serious threats ever to global public health. It kills more than 8 million people worldwide each year. More than 7 million of these are current or former users, and about 1.2 million are non-smokers involuntarily exposed to smoke.

All forms of tobacco are harmful and there is no threshold below which exposure is safe. Tobacco is most often consumed in the form of cigarettes, but there are other products such as water pipe tobacco, various smokeless tobacco products, cigars, cigarillos, roll-your-own tobacco, pipe tobacco, bidis and kreteks.

Smoking a water pipe is as harmful to health as smoking a cigarette, but consumers often have little knowledge of the health hazards of water pipes.

Smokeless tobacco use is highly addictive and harmful to health. Smokeless tobacco contains many carcinogenic toxins and its use increases the risk of cancer of the head, neck, throat, esophagus, and oral cavity (cancer of the mouth, tongue, lips, and gums) as well as several dental conditions.

More than 80% of the world’s 1.3 billion smokers live in low- and middle-income countries, where the burden of tobacco-related disease and death is greatest. Tobacco use contributes to poverty because households spend money on tobacco that they could have spent on basic needs such as food and shelter.

The economic costs of tobacco use are considerable: both the substantial costs of treating tobacco-related illnesses and the human capital lost to tobacco-related morbidity and mortality.

In some countries, children from poor households work in tobacco farming to supplement their family’s income. Tobacco farmers are also exposed to health risks, including “green tobacco disease.”

Monitoring is essential

Good surveillance provides insight into the size and nature of the tobacco epidemic and how best to adapt policies. Only 1 in 3 countries, representing 38% of the world’s population, monitors tobacco use among youth and adults by conducting nationally representative surveys at least every 5 years.

Main measures to reduce tobacco demand

Passive smoking kills

• Passive smoking is exposure to smoke from burned tobacco products such as cigarettes, bidis or water pipes in enclosed spaces.
• There is no threshold below which passive smoking is safe. It causes more than 1.2 million premature deaths per year as well as serious cardiovascular and respiratory disease.
• Nearly half of children regularly breathe air polluted by tobacco smoke in public places, and 65,000 die each year from diseases attributable to secondhand smoke.
• In infants, secondhand smoke increases the risk of sudden death, and in pregnant women, it causes pregnancy complications and low birth weight.
• Smoke-free laws protect the health of nonsmokers, are well accepted, do not adversely affect the economy, and encourage smokers to quit.

The illustrated warnings are effective

• Large pictorial or illustrated warnings, especially on plain packaging, that contain hard-hitting messages can convince smokers to protect the health of nonsmokers by not smoking indoors, increase compliance with nonsmoking laws, and encourage more smokers to quit.
• Studies show that pictorial warnings make people much more aware of the harms of smoking.
• Media campaigns can also reduce demand for tobacco by promoting nonsmoking protection and persuading people to quit.

Banning tobacco advertising lowers consumption

• Comprehensive bans on tobacco advertising, promotion, and sponsorship can lower tobacco consumption.
• A comprehensive ban addresses both direct and indirect forms of promotion.

• The direct forms include advertising on television, radio, in print publications, through billboards, and, more recently, on various social networking platforms.
• Indirect forms include brand exchange, brand extension, free distribution, price discounts, point-of-sale product displays, sponsorships, and promotional activities that the tobacco industry disguises as corporate social responsibility programs.

Taxes are effective in reducing tobacco consumption

• Tobacco taxes are the most effective way to reduce tobacco consumption and health care spending, particularly among youth and low-income people, while increasing tax revenues in many countries.
• The tax increase must be large enough that the price of tobacco increases more than revenues. A 10 percent price increase decreases consumption by about 4 percent in high-income countries, and by about 5 percent in low- and middle-income countries.
• Yet high tobacco taxation is a little-used measure in the arsenal of tobacco control measures.

Tobacco users need cessation assistance

• Studies show that few people know the specific health risks of tobacco use. But when they become aware of the dangers of smoking, most smokers want to quit.
• Without smoking cessation assistance, only 4% of quit attempts are successful.
• Professional help and medication with proven effectiveness in quitting smoking can more than double a smoker’s chances of success when trying to quit.

The illicit trade in tobacco products must be stopped

The illicit trade in tobacco products poses major health, economic, and security problems around the world. It is estimated that approximately one in 10 cigarettes or tobacco products consumed worldwide originates from the illicit market, which is carried out by a variety of actors, ranging from small-scale retailers to large tobacco companies, and sometimes to organized criminal networks involved in arms and human trafficking.

Tax evasion (legal) and tax fraud (illegal) undermine the effectiveness of tobacco control policies, including tax increases.

The tobacco industry and others often argue that high taxation of tobacco products creates incentives for tax evasion. However, experience in many countries shows that it is possible to combat illicit trade even with higher tobacco prices and taxes.

Ending the illicit trade in tobacco products is an achievable public health priority. But to do so requires improved national and subnational tax administration systems, as well as international collaboration. The Protocol to Eliminate Illicit Trade in Tobacco Products, a protocol to the WHO Framework Convention on Tobacco Control, provides a series of important measures and interventions to reduce tobacco consumption and its health and economic consequences.

New Tobacco and Nicotine-Containing Products

Heated tobacco products

Heated tobacco products are, like all tobacco products, inherently toxic and contain carcinogens. They must therefore be treated like all other tobacco products in tobacco control policies. They generate aerosols containing nicotine and other toxic chemicals when the tobacco is heated, or when a device containing the tobacco is activated (these include iQOS, Ploom, Glo and PAX vaporizers). The consumer inhales these aerosols by sucking or inhaling through a device. The aerosols contain nicotine, a highly addictive substance, non-tobacco additives and are often flavored.

In recent years, manufacturers have promoted heated tobacco products as “less harmful” or as an aid to quitting smoking. However, these products expose users to toxic emissions, many of which cause cancer, and there is currently insufficient evidence that they are less harmful than conventional cigarettes. There is also insufficient data on the effects of secondary emissions from heated tobacco products, although these emissions contain harmful or potentially harmful chemicals (1).

Electronic cigarettes

Electronic nicotine inhalers and non-nicotine inhalers, commonly referred to as electronic cigarettes, are devices that heat a liquid containing or not containing nicotine to produce an aerosol that is then inhaled by the user. The main constituents of the solution by volume are propylene glycol, with or without glycerol, and flavoring agents. Electronic cigarettes do not contain tobacco but are harmful to health and present risks. However, it is too early to have a clear idea of the long-term impact of using or being exposed to these products.

Electronic cigarettes are particularly dangerous when used by children and adolescents. Nicotine is highly addictive and young people’s brains continue to develop until about age 25.

Using electronic nicotine inhalers increases the risk of heart and lung disease. It also poses a significant risk to pregnant women because it can affect the growth of the fetus.

Advertising for, marketing of, and promotion of these devices has grown rapidly through channels that make extensive use of the Internet and social networks (2). Much of the marketing around these products raises concerns about misleading health claims, deceptive claims about their efficacy for smoking cessation, and strategies targeting youth (particularly the use of flavors).

Electronic inhalers with or without nicotine should not be promoted as cessation aids until there is sufficient evidence and consensus in the public health community that they are effective. WHO recommends that when not banned, these products should be regulated with the following four broad objectives:

• • prevent non-smokers, minors and vulnerable groups from using electronic inhalers;

and

• • reduce to the greatest extent possible the risks to users from electronic inhalers and protect nonusers from exposure to their emissions;

and

• prevent electronic inhalers from making unsubstantiated health claims; and
• ensure that tobacco control activities are not influenced by commercial and other interests related to electronic inhalers, including tobacco industry interests (3).

WHO Action

The human and economic tragedy for which tobacco is responsible is shockingly large, but it is also preventable. Multinational tobacco companies – and all tobacco manufacturers – fight to keep the dangers of their products hidden, but we fight back: in 2003, WHO Member States unanimously adopted the WHO Framework Convention on Tobacco Control. In force since 2005, it now has 182 Parties representing over 90% of the world’s population.

The WHO Framework Convention is a milestone in the promotion of public health. It is an evidence-based treaty that reaffirms the right of every human being to the highest attainable standard of health, provides a legal framework for international health cooperation and sets high standards for implementation. Strengthening the implementation of the Convention is part of the 2030 Agenda for Sustainable Development under target 3.a.

In 2007, WHO introduced the MPOWER program, a practical and cost-effective method to accelerate the implementation of the demand reduction provisions of the WHO Framework Convention on Tobacco Control on the ground. Each of the recommended measures corresponds to at least one provision of the WHO Framework Convention on Tobacco Control.

The 6 MPOWER measures are as follows:

• • (Monitor) Monitor tobacco use and prevention policies

.

• (Protect) Protect the public from tobacco smoke
• (Offer) Provide assistance to those who want to quit
• (Warn) To warn about the harms of smoking
• (Eforce) Enforce the ban on tobacco advertising, promotion and sponsorship
• (Raise) Increase taxes on tobacco

WHO has been tracking the implementation of MPOWER policies since 2007. For more information on progress in tobacco control at the global, regional, and country levels, see the series of reports published by WHO on the global tobacco epidemic. Brazil and Turkey are the only two countries that are fully implementing MPOWER measures at the highest level of implementation.

The WHO Report on the Global Tobacco Epidemic 2019, dedicated to smoking cessation assistance, is the seventh in a series of reports that provide updates on the tobacco epidemic and the measures in place to combat it.

The Protocol to Eliminate Illicit Trade in Tobacco Products provides for a comprehensive set of measures to address the tobacco supply chain, including licensing the import, export and manufacture of tobacco products, establishing tracking and tracing systems, and criminalizing those responsible for illicit trade. It also criminalizes illicit production and smuggling across borders. The Protocol to Eliminate Illicit Trade in Tobacco Products is the first Protocol of the Convention. It was adopted in November 2012 at the fifth session of the Conference of the Parties, held in Seoul, Republic of Korea, and entered into force in September 2018. To date, it has 58 Parties.

World No Tobacco Day is celebrated every year on May 31 around the world. It provides an opportunity to inform the public about the dangers of tobacco use, the business practices of tobacco companies, WHO’s work to combat the tobacco epidemic, and what everyone in the world can do to assert their right to health and a healthy lifestyle and to protect future generations. Learn more about the 2020 campaign.

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Literature references

(1) iQOS: evidence of pyrolysis and release of a toxicant from plastic.

(2) Huang J, Kornfield R, Szczypka G, Emery S. A cross-sectional examination of marketing of electronic cigarettes on Twitter. Tobacco Control. 2014; 23 (suppl 3): iii26-iii30.

(3) Electronic nicotine inhalers and non-nicotine containing electronic inhalers. Decision of the WHO Conference of the Parties to the WHO Framework Convention on Tobacco Control, sixth session, FCTC/COP/6(9), 2014.

* The WHO Framework Convention on Tobacco Control defines tobacco products as “products manufactured wholly or partly from leaf tobacco as raw material and intended to be smoked, sucked, chewed or snuffed.”