-- The global number of smokers continues to rise, with smoking causing 
     nearly 8 million deaths in 2019, including one in five male deaths. 
  -- 90% of new smokers become addicted by age 25 - preventing adolescents 
     from starting is crucial for changing the course of the epidemic for 
     the next generation. 
  -- Countries must meet their commitments to adopt and enforce effective 
     tobacco control policies including higher taxes on tobacco products. 
     Banning tobacco advertising, including via social media, and 
     smoke-free environments could help further prevent smoking initiation 
     among young people. 
  -- Although global age-standardised prevalence of smoking decreased 
     significantly between 1990 and 2019, similar progress was not observed 
     for chewing tobacco – with a 25% age-adjusted rate of use among men 
     over age 15 in South Asia. 

The most comprehensive data on global trends in smoking highlight its enormous 
global health toll. The number of smokers worldwide has increased to 1.1 
billion in 2019, with tobacco smoking causing 7.7 million deaths – including 1 
in 5 deaths in males worldwide. 

Logo - https://mma.prnewswire.com/media/1156878/IHME_Logo.jpg 

Of particular concern are the persistently high rates of smoking among young 
people, with over half of countries worldwide showing no progress in reducing 
smoking among 15-24 year olds. 89% of new smokers become addicted by age 25. 
Protecting young people from nicotine addiction during this critical window 
will be crucial to eliminate tobacco use among the next generation.

Using data from 3,625 nationally representative surveys, the three new studies 
published in The Lancet and The Lancet Public Health by the Global Burden of 
Disease collaboration, led by the Institute for Health Metrics and Evaluation, 
provide global estimates on smoking prevalence ( 
https://www.thelancet.com/journals/lancet/article/PIIS0140-67362101169-7/fulltext 
) in 204 countries in men and women aged 15 and over, including age of 
initiation ( 
https://www.thelancet.com/journals/lanpub/article/PIIS2468-26672100102-X/fulltext 
), associated diseases, and risks among current and former smokers, as well as 
the first analysis of global trends in chewing tobacco use ( 
https://www.thelancet.com/journals/lanpub/article/PIIS2468-26672100065-7/fulltext 
).

Published ahead of World No Tobacco Day (31st May), the authors call on all 
countries to urgently adopt and enforce a comprehensive package of 
evidence-based policies to reduce the prevalence of tobacco use and prevent 
initiation, particularly among adolescents and young adults. 

"Smoking is a major risk factor that threatens the health of people worldwide, 
but tobacco control is woefully insufficient in many countries around the 
world. Persistently high smoking prevalence among young people in many 
countries, along with the expansion of new tobacco and nicotine products, 
highlight an urgent need to double down on tobacco control. If a person does 
not become a regular smoker by age 25, they are very unlikely to become a 
smoker. This presents a critical window of opportunity for interventions that 
can prevent young people from starting smoking and improve their health for the 
rest of their lives," says Professor Emmanuela Gakidou, senior author, 
Institute for Health Metrics and Evaluation (IHME), University of Seattle, 
Washington. [1] 

Increasing number of smokers highlights uphill battle in global tobacco control 

Since 1990, global smoking prevalence among men decreased by 27.5% and by 37.7% 
among women. However, twenty countries saw significant increases in prevalence 
among men, and 12 saw significant increases among women.

In half of countries, reductions in prevalence have not kept pace with 
population growth, and the number of current smokers has increased. The ten 
countries with the largest number of tobacco smokers in 2019, together 
comprising nearly two-thirds of the global tobacco smoking population, are 
China, India, Indonesia, the USA, Russia, Bangladesh, Japan, Turkey, Vietnam, 
and the Philippines – one in three current tobacco smokers (341 million) live 
in China. 

In 2019, smoking was associated with 1.7 million deaths from ischaemic heart 
disease, 1.6 million deaths from chronic obstructive pulmonary disease, 1.3 
million deaths from tracheal, bronchus, and lung cancer, and nearly 1 million 
deaths from stroke. Previous studies have shown that at least one in two 
long-term smokers will die from causes directly linked to smoking, and that 
smokers have an average life expectancy ten years lower than never-smokers.

Approximately 87% of deaths attributable to smoking tobacco occurred among 
current smokers. Only 6% of global deaths attributable to smoking tobacco use 
occurred among individuals who had quit smoking at least 15 years previously, 
highlighting the important health benefits of cessation. 

7.4 trillion cigarette-equivalents of tobacco (combining smoked tobacco 
products include manufactured cigarettes, hand-rolled cigarettes, cigars, 
cigarillos, pipes, shisha, and regional products such as bidis and kreteks) 
were consumed in 2019, amounting to 20.3 billion each day worldwide. Countries 
with the highest consumption per person were mostly in Europe. Globally, one in 
three male and one in five female smokers consume 20 or more 
cigarette-equivalents per day. 

15-24 years: a critical window to change the course of the tobacco epidemic

"Behavioural and biological studies suggest that young people are particularly 
vulnerable to addiction, and with high rates of cessation remaining elusive 
worldwide, the tobacco epidemic will continue for years to come unless 
countries can dramatically reduce the number of new smokers starting each year. 
With nine out of ten smokers starting before the age of 25, ensuring that young 
people remain smoke-free through their mid-twenties will result in radical 
reductions in smoking rates for the next generation," says Marissa Reitsma, 
lead author of the studies on smoking, IHME. [1] 

In 2019, there were an estimated 155 million smokers aged between 15 and 24 
years – equivalent to 20.1% of young men and 5.0% of young women, globally.

Two-thirds (65.5%) of all current smokers began smoking by age 20, and 89% of 
smokers began by age 25. This highlights a critical age window during which 
individuals develop nicotine addiction and transition to become established 
smokers. 

In 12 countries and territories in 2019, more than one in three young people 
were current smokers, including Bulgaria, Croatia, Latvia, France, Chile, 
Turkey, and Greenland, as well as five Pacific islands.

Globally, smoking prevalence among young people decreased between 1990 and 2019 
among both young men (-32.9%) and young women (-37.6%). Progress varied across 
countries with only 81 achieving a significant decrease in prevalence among 
young people. More than half of countries experienced no change.  

In many countries, progress in reducing the prevalence of smoking has not kept 
pace with population increases, resulting in significant increases in the 
number of young smokers. India, Egypt, and Indonesia had the largest absolute 
increases in number of young male smokers. Turkey, Jordan, and Zambia had the 
largest increases in number of young female smokers. 

Globally, the average age at which individuals began smoking regularly is 19. 
The youngest average ages of initiation were observed in Europe and the 
Americas – with the youngest average age of initiation in Denmark (16.4). The 
oldest average ages of initiation were seen in east and south Asia and 
sub-Saharan Africa – with the oldest average age of initiation in Togo (22.5 
years).

Reitsma adds: "Notably, in countries where prevalence of smoking among young 
people has decreased significantly, the age at which people start smoking has 
remained constant across time. This is encouraging evidence that interventions 
prevent smoking altogether, as opposed to only delaying the age at which people 
start smoking." 

Stronger regulation of chewing tobacco needed, particularly in South Asia

Globally, 273.9 million people used chewing tobacco in 2019, equivalent to 
age-adjusted prevalence of 6.5% among men and nearly 3% among women over the 
age of 15. Most people (228.2 million; 83.3%) who used chewing tobacco in 2019 
resided in the South Asia region. The largest population of people who use 
chewing tobacco are in India with 185.8 million users, corresponding to 68% of 
all chewing tobacco users globally. Bangladesh, Nepal and Bhutan also had very 
high prevalence of chewing tobacco use.

"The health risks of chewing tobacco are well documented, including strong 
evidence of an increased risk of oral cancer. While global smoking prevalence 
has decreased, chewing tobacco has not, suggesting that control efforts have 
had much larger effects on the prevalence of smoking than on chewing tobacco in 
some countries. Stronger regulations and policies that specifically target use 
of chewing tobacco are needed, especially in countries in South Asia with high 
prevalence," says Parkes Kendrick, lead author of the study on chewing tobacco, 
IHME. [1] 

Industry interference and waning political commitment stalling urgent action on 
tobacco control

The first international public health treaty, the WHO Framework Convention on 
Tobacco Control (WHO FCTC), entered into force and became international binding 
law in 2005. The WHO FCTC outlines evidence-based interventions including 
reducing affordability of tobacco products through taxation, passing 
comprehensive smoke-free laws, restriction of sales to minors, mandating health 
warnings on packaging, and banning tobacco advertising, promotion, and 
sponsorship. 

Since 2005, the FCTC has been ratified by 182 parties, but, as of 2018, only 62 
countries had comprehensive smoke-free policies; 23 offered the full range of 
cessation support services; 91 mandated pictorial health warnings; 48 had 
comprehensive advertising, promotion, and sponsorship bans; and 38 had the 
recommended level of tobacco taxation. 

Tobacco taxation is a highly cost-effective measure, particularly when combined 
with a progressive approach to redistributing revenue from taxation to tobacco 
control programmes, health care, and other social support services. Decreasing 
affordability is particularly effective in reducing smoking rates among young 
people.

Between 2008 and 2018, the affordability of cigarettes decreased in only 33% of 
low-income countries compared with 38% in middle-income countries and 72% of 
high-income countries. Low-income and middle-income countries face the 
additional challenge of population growth expanding their smoking population. 
Despite this, only one low-income country, Madagascar, taxes tobacco at the 
rate recommended by WHO. 

As the tobacco industry innovates by leveraging social media, tobacco control 
strategies must also evolve. Flavours may also play an important role in 
attracting youth to tobacco, in particular with the emergence of e-cigarette 
use. Banning all characterizing flavours, including menthol, across all 
nicotine-containing products, including smoked tobacco products, smokeless 
tobacco products, e-cigarettes, and heated tobacco products is a promising 
approach to reducing demand among young people. 

Most countries have their legal purchase age set at either 16 or 18, but three 
quarters of smokers start by the age of 21. The authors point to encouraging 
evidence from some studies showing the impact of increasing the legal purchase 
age may have on smoking rates. Globally, the highest observed minimum age of 
purchase at the national level is 21, with six countries (the USA, Uganda, 
Honduras, Sri Lanka, Samoa, and Kuwait) at this benchmark. 

Dr Vin Gupta, co-author, IHME, says: "Despite progress in some countries, 
tobacco industry interference and waning political commitment have resulted in 
a large and persistent gap between knowledge and action on global tobacco 
control. Bans on advertising, promotion, and sponsorship must extend to 
internet-based media, but only one in four countries have comprehensively 
banned all forms of direct and indirect advertising. Despite the clear link to 
youth initiation, fewer than 60 countries have enacted even partial flavour 
bans on tobacco products. Closing these loopholes is critical to protecting 
young people from the influence of the tobacco." [1] 

Finally, the authors note limitations across the three studies, including that 
data on tobacco use are self-reported, age of initiation may be subject to 
recall bias, and the health effects of smoking do not include second hand 
smoke. The analyses focus on smoking tobacco products and chewing tobacco 
products and do not reflect e-cigarettes (and other electronic nicotine 
delivery systems) or heated tobacco products. 

In a linked Comment, Alan Blum and Ransome Eke, University of Alabama, 
Tuscaloosa, USA (who were not involved in the study) write: "How to tackle the 
global smoking pandemic has become a perpetual dilemma. Tobacco control—a term 
adopted by 1990s academia to keep radical grassroots antismoking activism at 
arm's length—remains mired in descriptive research that generates data to 
support policies aimed at reducing smoking. However, unlike, for instance, 
mosquito control, the vector—the tobacco industry—survives and thrives. And, 
like a mutating virus, it adapts to legislative and regulatory attempts to 
hinder the sale, promotion, and use of its products. Taxation or sin taxes are 
not necessarily the most effective tobacco control policy, but to say so risks 
derision. Cigarette taxes could be set high enough to crush the tobacco 
industry, but no governments will go that far. They rely on this revenue for 
deficit reduction and for things other than curbing smoking…. The tobacco 
industry remains the foremost obstacle to tobacco control. State-owned 
cigarette manufacturers— notably, the China tobacco monopoly in the world's 
largest cigarette market—pose a daunting challenge to public health. The USA, 
the UK, Japan, Korea, Switzerland, and Sweden, among other countries, also host 
powerful tobacco companies… Any hope for ending the tobacco pandemic lies in 
the commitment of every health professional to make smoking prevention, smoking 
cessation, and relapse prevention a top priority."

NOTES TO EDITORS
The research was funded by Bloomberg Philanthropies and the Bill & Melinda 
Gates Foundation.

[1] Quote direct from author and cannot be found in the text of the Article.

Article on global trends in smoking tobacco (The Lancet) 
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01169-7/fulltext 

Article on youth initiation (The Lancet Public Health) 
http://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(21)00102-X/fulltext 

Article on chewing tobacco (The Lancet Public Health) 
http://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(21)00065-7/fulltext 


Source- Institute for Health Metrics and Evaluation

CONTACT: Amelia Apfel, (206) 359-5111, arapfel@uw.edu