A systematic analysis from the Global Burden of Disease Study 2019
27 May 2021
GBD 2019 Tobacco Collaborators. Source: The Lancet
Summary
Background
Ending the global tobacco epidemic is a defining challenge in global health. Timely and comprehensive estimates of the prevalence of smoking tobacco use and attributable disease burden are needed to guide tobacco control efforts nationally and globally.
Methods
We estimated the prevalence of smoking tobacco use and attributable disease burden for 204 countries and territories, by age and sex, from 1990 to 2019 as part of the Global Burden of Diseases, Injuries, and Risk Factors Study. We modelled multiple smoking-related indicators from 3625 nationally representative surveys. We completed systematic reviews and did Bayesian meta-regressions for 36 causally linked health outcomes to estimate non-linear dose-response risk curves for current and former smokers. We used a direct estimation approach to estimate attributable burden, providing more comprehensive estimates of the health effects of smoking than previously available.
Findings
Globally in 2019, 1·14 billion (95% uncertainty interval 1·13–1·16) individuals were current smokers, who consumed 7·41 trillion (7·11–7·74) cigarette-equivalents of tobacco in 2019. Although prevalence of smoking had decreased significantly since 1990 among both males (27·5% [26·5–28·5] reduction) and females (37·7% [35·4–39·9] reduction) aged 15 years and older, population growth has led to a significant increase in the total number of smokers from 0·99 billion (0·98–1·00) in 1990. Globally in 2019, smoking tobacco use accounted for 7·69 million (7·16–8·20) deaths and 200 million (185–214) disability-adjusted life-years, and was the leading risk factor for death among males (20·2% [19·3–21·1] of male deaths). 6·68 million [86·9%] of 7·69 million deaths attributable to smoking tobacco use were among current smokers.
Interpretation
In the absence of intervention, the annual toll of 7·69 million deaths and 200 million disability-adjusted life-years attributable to smoking will increase over the coming decades. Substantial progress in reducing the prevalence of smoking tobacco use has been observed in countries from all regions and at all stages of development, but a large implementation gap remains for tobacco control. Countries have a clear and urgent opportunity to pass strong, evidence-based policies to accelerate reductions in the prevalence of smoking and reap massive health benefits for their citizens.
Funding
Bloomberg Philanthropies and the Bill & Melinda Gates Foundation.
Introduction
Over the past 30 years, more than 200 million deaths have been caused by smoking tobacco use, and annual economic costs due to smoking tobacco use exceed US$1 trillion.1, 2
With more than 1 billion current smokers globally in 2019, these numbers are likely to increase over the coming decades. The enormous health and economic consequences of the global tobacco epidemic make tobacco control a clear and urgent public health priority.3
Effective implementation and enforcement of tobacco control policies and interventions can both increase healthy life expectancy and decrease health-care costs.4, 5, 6, 7
Despite the clear benefits, progress in tobacco control has varied substantially across countries.
The first international public health treaty, the WHO Framework Convention on Tobacco Control (FCTC), entered into force and became an international binding law in 2005.8
Consensus on the importance of tobacco control led 182 countries to ratify the treaty, which outlines a suite of recommended demand-reduction tools. These tools include reducing affordability through taxation, passing smoke-free laws, mandating health warnings on packaging, and banning tobacco advertising, promotion, and sponsorship.9
15 years after the FCTC entered into force, a large implementation gap remains. WHO has monitored the implementation of the FCTC articles using the MPOWER framework for more than a decade.10
Over this period, only two countries, Brazil and Turkey, have implemented all the demand-reduction policies included in MPOWER at their highest level.10
Nonetheless, progress has been made in expanding coverage of best-practice policies, with the number of countries implementing at least one best-practice policy increasing from 43 in 2007 to 136 in 2018.10
The global importance of non-communicable diseases has led to their inclusion at the forefront of global progress targets, including a goal of 25% reduction in premature mortality from non-communicable diseases by 2025 outlined in the WHO global non-communicable disease monitoring framework and a third reduction by 2030 included in the UN Sustainable Development Goals (SDGs).11, 12
Tobacco control has been identified as a crucial and necessary part of reaching these goals, with one in six non-communicable disease-related deaths being attributable to smoking tobacco use.13, 14, 15, 16, 17
As countries work towards meeting global progress targets for reducing the prevalence of smoking tobacco use and premature mortality from non-communicable diseases, timely data on the prevalence of smoking tobacco use and attributable disease are necessary to guide effective policy and planning.11, 17
The public health significance of smoking tobacco use has resulted in a long tradition of estimating patterns of smoking tobacco use and its health effects.17, 18, 19, 20, 21
Estimates of the attributable burden of smoking tobacco use have been included in the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) since its initial publication in 1997.22
Previous studies estimating the attributable burden of tobacco smoking have combined indirect estimation using the Smoking Impact Ratio method for cancers and chronic obstructive pulmonary disease, which uses observed lung cancer mortality to indirectly estimate the disease burden attributable to tobacco smoking, with direct estimation using lagged prevalence of daily smoking tobacco use for cardiovascular and circulatory diseases and all other health outcomes.20, 23, 24
For health outcomes modelled using daily prevalence, risks among occasional smokers and former smokers were not included, and methods did not reflect well described dose-response associations between smoking intensity and risk of disease. For the health outcomes modelled using the Smoking Impact Ratio method, reliability was low in countries with either scare or poor quality data on lung cancer mortality and in countries with other important competing risks for lung cancer, such as air pollution.
The objective of this study, which is part of GBD 2019, was to update and improve previous estimates of global trends in the prevalence of tobacco smoking and tobacco smoking-attributable disease for 204 countries and territories, by age and sex, from 1990 to 2019. Using new methods and new data, we aimed to provide novel insights into patterns of smoking intensity and their association with health outcomes that are directly relevant to guiding tobacco control efforts nationally and globally. This manuscript was produced as part of the GBD Collaborator Network and in accordance with the GBD Protocol.
