number of deaths (’000s) in 1998 attributable to tobacco use who region males females world health...
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Public Health Effectsof Tobacco Dependence
Lars M. RamströmInstitute for Tobacco Studies
Stockholm, Sweden
Number of deaths (’000s) in 1998 attributable to tobacco use
WHO Region Males Females
World Health Report 1999
All member states 3,241 782
Africa 112 13
The Americas 472 300
Eastern Mediterranean 160 22
Europe 1,066 207
South-East Asia 505 75
Western Pacific 927 166
A measure of burden of disease capturing the impact of both premature deaths and disability
DALYs
Disability Adjusted Life Years
One DALY is one lost year of healthy life
Deaths respectively DALYs attributable to selected risk factors in 1990.
Established Market Economies ( OECD)
Risk factor % of deaths
% of DALYs
Malnutrition 0.0 0.0 Poor water, sanitation 0.0 0.1 Unsafe sex 0.8 2.0 Tobacco 14.9 11.7 Alcohol 1.2 10.3 Occupation 2.2 5.0 Hypertension 11.1 3.9 Physical inactivity 11.7 4.8 Illicit drugs 0.4 2.3 Air pollution 0.9 0.5
Deaths respectively DALYs attributable to selected risk factors in 1990.
World as a whole
Risk factor % of deaths
% of DALYs
Malnutrition 11.7 15.9 Poor water, sanitation 5.3 6.8 Unsafe sex 2.2 3.5 Tobacco 6.0 2.6 Alcohol 1.5 3.5 Occupation 2.2 2.7 Hypertension 5.8 1.4 Physical inactivity 3.9 1.0 Illicit drugs 0.2 0.6 Air pollution 1.1 0.5
Source: Murray CJL, Lopez AD. 1996.
DALYs attributable to tobacco use
% of total in
Region 1990 2020
World 2.6 8.9Developed Regions 12.1 18.2Developing Regions 1.4 7.7
Source: Murray CJL, Lopez AD. 1996 DALYs attributable to tobacco use % of total in
Region 1990 2020
Est. Market Economies 11.7 17.0 Former Socialist Econ. of Europe 12.5 19.9
India 0.6 10.2China 3.9 16.1Sub-Saharan Africa 0.4 1.7Latin America & Carib. 1.4 6.8
Murray CJL, Lopez AD. 1996
”By 2020, tobacco is expected to cause more
premature death and disability than any single
disease.”
Why do people smoke?
P. Hajek 2001
• Initiation - social reasons
• Maintenance - pharmacological reasons
Smokers have low degree of control over their behaviour
P. Hajek 2001
• Most smokers say they want to quit
• Over 95% of smokers rarely if ever go a day without a cigarette
• Over 97% of quit attempts last <6 months
• Some 70% resume smoking after a major smoking related health crisis
Are smokers addicted?
Are smokers addicted?
P.Hajek 2001
Signs of addiction include
• Continued use despite knowledge of harmful effects
• Witdrawal symptoms and urges to use the drug during abstinence
• Failure of attempts to stop
WHO ICD 10International Classification of DiseasesF10-F19 Mental and Behavioural Disorders Due to Psychoactive substance use
F10 Disorders resulting from use of alcohol
F11 Disorders resulting from use of opiods
F12 Disorders resulting from use of cannabinoids
F13 Disorders resulting from use of sedatives or hypnotics
F14 Disorders resulting from use of cocaine
F15 Disorders resulting from use of other stimulants
F16 Disorders resulting from use of hallucinogens
F17 Disorders resulting from use of tobacco
F18 Disorders resulting from use of volatile solvents
F19 Disorders resulting from multiplw drug use and use of other psychoactive substances
Intervention strategies for reduction of tobacco-related death and disability
• Decreasing onset of tobacco use
• Increasing cessation
• Finding less harmful kinds of tobacco use
Less harmful tobacco use”Light” cigarettes ?Generally no benefit. Low nicotine yield may even
increase health risks unless tar/nicotine ratio is kept extra low
Smokeless tobacco ?Most kinds of smokeless tobacco involve severe
health risks. However, Swedish ”snus” (a special kind of moist
oral snuff) has been recognized as substantially less harmful than smoking
Intervention to decrease onset
Potential:In principle it represents a long term solution
Difficulties:It cannot yield an appreciable reduction of mortality
during the nearest 40 years - only later, when today’s young people reach ages >55
Social pressure to smoke can be very strong and intervention programmes have limited success
Intervention to increase cessation
Potential:Mortality reduction occurs quite rapidly after
successful intervention
Widespread cessation contributes to a social climate that favours prevention of onset
Difficulties:Smokers must be given both:- motivation to quit, and - support to overcome their dependence
Three intervention scenarios as basis for:
Projections of premature tobacco deaths for periods 2000-2024 and 2025-2049 Peto R. et al 1998
• No intervention (current trends persisting)
• Intervention to decrease onset (halving uptake of smoking by 2020)
• Intervention to increase cessation (halving global cigarette consumption by 2020)
SUMMARY (1)NOWAmong 10 selected risk factors for disease and disabilty(incl. e.g. malnutrition, alcohol, illegal drugs, unsafe sex)
IN THE DEVELOPED REGIONS:Tobacco causes the heaviest burden both in terms ofpremature deaths and DALYs
IN THE WORLD AS A WHOLE:Tobacco comes second only to malnutrition as a cause ofpremature deaths
BY 2020Tobacco is expected to cause more premature deaths anddisability than any single disease(if current smoking patterns persist)
SUMMARY (2)DURING THE FIRST HALF OF THIS CENTURY
The smoking-related burden of disease and disability:
– CANNOT be significantly reduced by prevention of onset
– CAN be significantly reduced by large scale smoking cessation
DURING THE SECOND HALF OF THIS CENTURY
– Current efforts to prevent onset start to reduce smoking-related disease and disability
– Smoking cessation continues to be a major means ofreduction of smoking-related disease and disability