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close this bookFact sheet No 118: The Tobacco Epidemic: A Global Public Health Emergency Tobacco Use - May 1996 (WHO, 1996, 6 p.)
View the document(introduction...)
View the documentThe Tobacco Epidemic: A Global Public Health Emergency Tobacco Use
View the documentSmoking Prevalence
View the documentHealth Effects
View the documentTobacco Production and Trade
View the documentEconomics of Tobacco
View the documentTobacco Control Measures

(introduction...)

May 1996

The Tobacco Epidemic: A Global Public Health Emergency Tobacco Use

By the end of the 20th century, manufactured cigarettes have come to be the predominant form by which tobacco is consumed around the world. However there are many other methods by which tobacco is consumed, and in some regions, these other forms predominate. In India, for example, eight times more bidis (tobacco wrapped in a temburni leaf, widely consumed on the Indian subcontinent) than manufactured cigarettes are consumed annually.

· Between 65-85% of global tobacco consumption is in the form of cigarettes including bidis and kreteks (clove-flavoured cigarettes, particularly popular in Indonesia). An additional 15-35% of tobacco is consumed in the form of all other tobacco products.

· Global consumption of cigarettes per adult has remained steady from the early 1970s to the early 1990s, however, as the global population has continued to increase the absolute number of cigarettes consumed has continued to increase. WHO has estimated that a total of 6.05 x 1012 cigarettes were consumed annually in the period 1990-92. Unmanufactured tobacco consumption increased at about the same rate in the early 1990s, and by 1994, global consumption totalled 7 million tonnes.

· According to WHO estimates, there are around 1.1 thousand million smokers in the world, about one-third of the global population aged 15 years and over.

· In recent years, tobacco use has been declining in many countries of North America and Western Europe, but increasing in many developing countries, particularly in Asia.

· For the period 1970-72 to 1990-92, cigarette consumption has increased in some regions and decreased in others. For example, consumption decreased in the American Region and increased most rapidly in the Western Pacific Region. Although consumption has decreased in developed countries since 1980-82, this decrease has been counterbalanced by a comparable increase (1.4% per year) in less developed countries. Global cigarette consumption has remained relatively steady at about 1650 cigarettes per adult from the period 1980-82 to 1990-92.

· In China, the growth in estimated per capita consumption of cigarettes has been particularly rapid, increasing by 260% from the early 1970s to the early 1990s, with consumption estimated at around 1900 cigarettes per adult per year. In China there are about 300 million smokers, about the same number as in all developed countries combined.

· China , the world's most populous country is also the world's leading consumer of cigarettes. The world's second most populous country, India ranks only 14th for manufactured cigarettes, however when bidis are taken into account, India ranks second globally for total cigarette consumption.

· Substantially fewer cigarettes are smoked per day per smoker in developing countries than in developed countries. In the early 1990s, average adult per capita consumption in developed countries was 2590 vs 1410 in developing countries. However, the gap in per adult cigarette consumption is narrowing. Unless effective tobacco control measures take place, daily cigarette consumption in developing countries is expected to increase as economic development results in increased real disposable income. If current trends continue, per adult consumption in developing countries will exceed that of developed countries shortly after the turn of the century.

· There has been a dramatic shift if the group of countries with the highest rates of per adult tobacco consumption from the early 1970s to the early 1990s. In the early 1970s, consumption was highest in Canada, Switzerland, Australia and the UK while in the early 1990s, it was highest in Poland, Greece, Hungary, Japan, and the Republic of Korea.

· WHO is concerned about the decreasing age of smoking initiation. Data revealed that in many countries, the median age of smoking initiation was under the age of 15. This is of particular concern, since starting to smoke at younger ages increases the risk of death from a smoking-related cause. Among those who continue to smoke throughout their lives, about half can be expected to die from a smoking-related cause, with half of those deaths occurring in middle age. In countries such as France and Spain where more than 40% of young people aged 18-24 smoke (and most beginning at an early age) a very heavy future death toll from tobacco use can be expected.

Smoking Prevalence

The WHO report provides first-time estimates of worldwide smoking prevalence, based on surveys conducted in 87 countries, accounting for 85% of the world's population.

· Globally, approximately 47% of men and 12 % of women smoke.

· In developing countries, available data suggest that 48% of men smoke, as do 7% of women, while in developed countries, 42% of men and 24% of women smoke.

· Of the 87 countries for which data was available, male smoking prevalence is 50% or more in 22 countries, while female smoking prevalence is 25% or more in 26 countries.

· In countries with established market economies, male smoking prevalence averages around 37%, compared to 60% in the countries of Central and Eastern Europe.

· Smoking among women is most prevalent in the countries of Central and Eastern Europe (28%), countries with established market economies (23%) and Latin American and Caribbean countries (21%). In all other regions, fewer than 10% of women smoke.

· About one-third of regular smokers in developed countries are women, compared with only about one in eight in the developing world.

· Three countries, the Russian Federation, Poland and Fiji rank in the top twenty for both male and female smoking prevalence.

Health Effects

Tobacco is estimated to have caused around 3 million deaths a year in the early 1990s, and the death toll is steadily increasing. Unless current trends are reversed, that figure is expected to rise to 10 million deaths per year by the 2020s or the early 2030 (by the time the young smokers of today reach middle and older ages), with 70% of those deaths occurring in developing countries. The chief uncertainty is not whether these deaths will occur, but exactly when.

· The increase in the epidemic of smoking caused mortality in developed countries is slowing somewhat among men, but continues to increase rapidly among women, even if the epidemic of smoking-related death is not as advanced as among men. In the mid 1990s, about 25% of all male deaths in developing countries were due to smoking, and among middle aged med (aged 35-69), more than one-third of all deaths were caused by smoking.

· For middle-aged women in developed countries, the percentage of all deaths caused by smoking increased more than six-fold, from 2% in 1955 to 13% in 1995, and continues to increase rapidly.

· Of all the diseases causally associated with smoking, lung cancer is the most well known, largely because in most populations, almost all lung cancer deaths are due to smoking. However, smoking actually causes more deaths from diseases other than lung cancer. In 1995, there were 514,000 smoking-caused lung cancer deaths in developed countries, compared to 625,000 smoking attributable deaths from heart and other vascular diseases in the same year.

· Smokeless tobacco also poses serious health risks. The annual mortality from tobacco chewing in South Asia alone may well be of the order of 50 000 deaths a year.

Tobacco Production and Trade

· Most of the global tobacco manufacturing industry is controlled by a small number of state monopolies and multinational corporations. The largest of these is the state monopoly in China, which in 1993 sold 1.7x 1012 cigarettes, which represented 31% of the global market. In 1993, the seven largest multinational tobacco corporations accounted for nearly 40% global cigarette sales.

· China is the world's dominant producer of unmanufactured tobacco, producing as much as the next 7 largest producers combined. While tobacco is grown in over 100 countries, the 25 leading producers account for over 90% of global tobacco production.

· Worldwide, around 5.5x 1012 cigarettes were manufactured in 1994, with just four countries, China, the US, Japan and Germany accounting for over half of global production.

· Some countries which are major importers of cigarettes, such as Japan, France, and the Russian Federation are also major consumers of these products. Other major importing countries, such as Hong Kong, the Netherlands, Singapore, and Germany are major regional distribution centres that re-export a large percentage of the cigarettes they import.

· Countries that import large amounts of unmanufactured tobacco are usually major tobacco manufacturing centres. Most of them, such as the United States, Germany, the Russian Federation and Japan are also major consumers of manufactured tobacco.

· The United States is a major cigarette production centre and the world's leading exporter of manufactured cigarettes.

· For a number of years, the United States was the world's leading exporter of unmanufactured tobacco. However, by 1994, it had been surpassed by Brazil and Zimbabwe, the two leading sources of internationally traded unmanufactured tobacco as of the mid 1990s.

· Just five countries, Brazil, Zimbabwe, the United States, Turkey and Italy account for over half of all global exports of unmanufactured tobacco.

· Tobacco is also economically important in Brazil, the world's largest tobacco leaf exporter.

· In theory, world cigarette exports should equal imports, minus a small amount for transit time. In the early 1990s, exports exceeded imports by an estimated 282 000 million cigarettes, representing 5% of global cigarette production and 30% of cigarettes in international trade. Although the exact amount is difficult to quantify, a large percentage of this discrepancy is undoubtedly due to smuggling.

Economics of Tobacco

· Although tobacco is grown in over 100 countries, tobacco leaf and manufactured tobacco exports account for more than 8% of export earnings in just two countries, Malawi and Zimbabwe. Tobacco accounts for 64% of all export earnings in Malawi and 23% in Zimbabwe. However, tobacco represents a much smaller proportion of export earnings in all other countries.

· All countries that are devoting more than one percent of their total import expenses to purchasing tobacco are either developing countries or countries of Central and Eastern Europe. In these countries, expenditures on tobacco imports are relatively large, and are a significant cost to economic development.

· Although developed countries, particularly the United States earn the most money from tobacco exports, these earnings are less than one per cent of all their export earnings.

· High economic dependency on tobacco exports may make it more challenging to implement comprehensive tobacco control policies in countries such as Malawi and Zimbabwe. However, in such countries, tobacco control strategies would benefit from including measures to encourage appropriate economic adjustment as the global demand for tobacco slowly declines.

Tobacco Control Measures

From 1970 to 1995, the World Health Assembly adopted 14 resolutions, all without dissent, in favour of tobacco control measures. Several of these resolutions called for comprehensive tobacco control programmes and policies.

· Although these resolutions were adopted without dissent, many Member States have experienced difficulty in effectively implementing the comprehensive tobacco control strategies called for by the WHA resolutions. Among Member States, the range of policies and programmes which have been implemented vary widely.

· Many elements of an effective comprehensive national tobacco control policy will eventually involve some form of legislative action, whether in the form of adopting or amending laws, regulation or government decrees. However, even though countries may adopt legislation, in a number of cases, ineffective enforcement may render the legislation ineffective.

· In the early 1990s, about 25 countries had laws that prohibited the sale of cigarettes to minors, with the age of prohibition ranging from 16 to 21 years of age. In some cases, other related measures have been enacted, including bans or restrictions on cigarette sales from vending machines, prohibitions on sales of tobacco products and smoking in schools, prohibiting the sale of single cigarettes and banning the offering of free samples of cigarettes.

· In order to provide complete protection from involuntary exposure to tobacco smoke in indoor locations, smoking must be prohibited entirely or restricted to a few separately ventilated smoking areas. Some degree of protection is also provided by restricting smoking to a few specific rooms, even if separate ventilation is not feasible. Many jurisdictions have laws that ban or restrict smoking in public places, workplaces and transit vehicles.

· Effective health promotion and health education programmes are part of a comprehensive tobacco control programme. These include such features as celebration of no-tobacco days, media advocacy, the use of paid media advertising, school-based health promotion programmes, community-based health promotion programmes and sponsorship of cultural, sporting and community events. Many countries have successfully offset the costs of operating such programmes with a portion of the revenue collected from tobacco taxes.

· Smoking cessation strategies work best when they take place in as part of a comprehensive tobacco control programme. The best smoking cessation strategies would train all health professionals in the providing of smoking cessation counselling and advice. It would also be desirable to make available a broad range of cessation strategies, including group counselling, physician advice, and where appropriate, nicotine replacement therapy.

· There are active programmes to train pharmacists in smoking cessation counselling in Belgium, Denmark and the United Kingdom, with more European countries expected to follow suit. Telephone counselling services (quit lines) to assist people who wish to quit smoking are offered in a number of Member States. In Australia and South Africa, quit line telephone numbers are included along with required health information printed on every package of cigarettes.

· In the early 1990s, about 80 countries required health warnings to appear on packages of tobacco products. However, in most of these countries, the warnings are small, inconspicuous and provide little information about the many serious health consequences of tobacco use. By the mid 1990s, however, a number of countries had adopted more stringent warning systems, involving direct statements of health hazards, multiple messages, and well as large and prominent display. Such warnings are presently required in a number of countries including Australia, Canada, Iceland, Norway, Singapore, South Africa and Thailand.

· A number of countries have successfully passed law to ban all or nearly all forms of tobacco advertising. In a number of countries, further legislative active has proven necessary to tighten advertising restrictions, as tobacco companies have attempted to circumvent the ban by the use of indirect advertising.

· As of 1990, 27 countries reportedly had total or near-total bans on advertising. Since then, however, the number has declined to 18. While Australia and Kuwait recently implemented bans on tobacco advertising, tobacco advertising bans that had been in place became inoperative in Canada and the newly independent states of Central and Eastern Europe. However, Canada and many Central and East European countries are considering draft legislation to re-establish bans on tobacco advertising.

· Financial measures are an important component of comprehensive tobacco control strategies. A number of studies have shown that for every 10 per cent increase in the price of cigarettes, consumption can be expected to decline by two to eight percent, with even larger declines found among adolescents.

· Among Member States, cigarettes prices were found to vary widely. However, global comparison can be made by measuring the price of cigarettes in the minutes of labour required to earn the price of a packet of 20 cigarettes. Using this method of comparison, cigarettes were found to be most expensive in such countries as Jamaica, Costa Rica and Belize, while relatively inexpensive in Argentina, Japan and Spain.

· Regular increases in tobacco taxes which increase tobacco prices at rates faster than the general growth in prices and incomes will both reduce consumption and raise government revenue. Several countries were found to have taxes representing 60-80% of the retail price of cigarettes.

· A number of countries have successfully used a portion of tobacco taxation revenue to offset the cost of operating their comprehensive tobacco control programmes. In several Australian States, tobacco taxes are used to finance Health Promotion Foundations. A similar foundation exists in New Zealand funded from general revenue. In Finland, 0.45% of tobacco taxation revenue is allocated for tobacco control activities. In other countries, such as Nepal, Portugal, Romania and Switzerland, a portion of tobacco tax revenue is used to finance specific health or social programmes.

· Several WHO Member States have long-standing comprehensive tobacco control policies, built up gradually since the 1970s. As of the mid 1990s, Finland, Iceland, Norway, Portugal and Singapore fit into this category. Other countries, such as Australia, France, New Zealand, Sweden and Thailand have more recently implemented truly comprehensive tobacco control programmes which encompass most or all of the nine elements called for by the 1986 World Health Assembly resolution.

For further information, please contact Philippe Stroot, Media Relations, Health Communications and Public Relations, WHO, Geneva. Telephone (41 22) 791 2535. Fax (41 22) 791 4858.

All WHO Press Releases, Fact Sheets and Features can be obtained on Internet on the WHO home page http: //www.who.ch/

© WHO/OMS, 1998