Cigarette-Related Mortality in Different Countries

“milestone”฀in฀various฀countries,฀only฀one฀in฀ive฀smokers฀survives฀this฀milestone.฀The฀ opposite฀picture฀is฀found฀in฀the฀OECD฀countries:฀without฀the฀use฀of฀tobacco฀one-ifth฀of฀ people฀die฀before฀reaching฀the฀age฀of฀70,฀and฀deaths฀among฀non-smokers฀before฀the฀age฀of฀ 70฀are฀declining฀all฀the฀time฀ [43] . The฀statistics฀calculated฀for฀1990฀are฀impressive:฀for฀all฀countries฀together,฀mortality฀ from฀smoking฀was฀24฀and฀in฀the฀35–69-year-old฀age฀group,฀mortality฀was฀35฀for฀men฀ and฀12฀for฀women฀ [43] .฀The฀loss฀of฀life฀for฀a฀smoker฀is฀calculated฀at฀5–7฀years.฀In฀ several฀countries฀France,฀the฀Netherlands,฀Sweden,฀there฀has฀been฀an฀increase฀in฀ciga- rette฀consumption฀in฀young฀women฀in฀particular,฀with฀the฀result฀that฀increased฀mortality฀ must฀be฀anticipated฀in฀the฀decades฀ahead฀ [40] ฀Figs.฀ 2.6 ฀and฀ 2.7 .฀The฀summarised฀data฀ indicate฀that฀no฀smoking-related฀deaths฀occurred฀in฀people฀below฀the฀age฀of฀35฀ [43] .฀ Approximately฀ half฀ of฀ all฀ smokers฀ from฀ the฀ developing฀ countries฀ suffered฀ from฀ their฀ smoking฀behaviour.฀Teenagers฀or฀young฀adults฀who฀become฀regular฀smokers฀must฀expect฀ to฀forfeit฀8฀years฀of฀life฀ [43] ,฀as฀also฀shown฀by฀a฀study฀among฀British฀doctors฀conducted฀ over฀a฀40-year฀period฀ [23] . Table 2.3 ฀฀฀Numbers฀and฀percentages฀of฀smoking-related฀deaths฀in฀OECD฀countries฀in฀1990 Country Men Women 35–69฀ years 70฀years All฀ages 35–69฀ years 70฀years All฀ages Australia 6.7฀28 7.3฀21 14.0฀22 1.9฀15 3.1฀8 5.0฀9 Austria 4.0฀28 3.6฀16 7.5฀20 0.6฀7 1.5฀4 2.0฀5 Belgium 7.9฀41 8.6฀28 16.5฀31 0.7฀6 0.6฀1 1.2฀2 Canada 13.5฀35 14.1฀24 27.6฀27 5.0฀23 7.0฀11 12.1฀14 Denmark 3.3฀32 4.3฀22 7.6฀25 1.8฀27 2.6฀11 4.4฀15 Finland 2.6฀25 2.7฀21 5.3฀21 0.2฀5 0.5฀3 0.8฀3 France 32.6฀32 24.5฀16 57.1฀21 1.0฀2 1.2฀1 2.2฀1 Germany 52.0฀32 43.3฀18 95.3฀22 6.2฀7 10.4฀3 16.5฀3 Greece 5.2฀33 5.2฀17 10.4฀21 0.4฀5 0.9฀3 1.3฀3 Ireland 1.7฀31 2.5฀24 4.2฀25 0.7฀20 1.6฀15 2.3฀16 Italy 37.8฀37 34.9฀21 72.7฀26 2.7฀5 7.4฀4 10.1฀4 Japan 26.8฀16 41.5฀16 68.3฀15 3.6฀4 15.4฀6 19.0฀5 Luxemburg 0.2฀34 0.3฀25 0.5฀27 0.1฀9 0.1฀1 0.1฀3 Netherlands 8.6฀38 13.0฀32 21.6฀32 1.4฀11 1.3฀3 2.7฀4 New฀Zealand 1.4฀28 1.7฀22 3.1฀22 0.7฀21 0.8฀9 1.4฀11 Norway 1.4฀21 1.9฀12 3.4฀14 0.4฀12 0.6฀3 1.0฀5 Portugal 4.0฀21 2.8฀9 6.5฀13 0.0฀0 0.0฀0 0.0฀0 Spain 20.5฀33 19.4฀19 40.0฀23 0.0฀0 0.0฀0 0.0฀0 Sweden 2.1฀16 3.2฀9 5.3฀11 0.7฀10 1.3฀3 2.0฀4 Switzerland 3.1฀31 3.7฀18 6.8฀21 0.3฀6 0.9฀3 1.2฀4 United฀ Kingdom 37.2฀35 52.1฀27 89.4฀28 16.4฀24 32.1฀13 48.5฀15 USA 150.0฀36 136.2฀23 286.3฀26 72.7฀28 102.1฀14 174.9฀17 Total 423.5฀32 427.8฀20 851.3฀23 117.7฀16 191.6฀7 309.3฀9 Numbers฀of฀deaths฀in฀1,000s;฀percentages฀in฀parentheses฀ [43] It฀is฀estimated฀that฀in฀the฀year฀2000,฀smoking฀caused฀4.83฀million฀premature฀deaths฀in฀ the฀world,฀2.41฀million฀in฀developing฀countries฀and฀2.43฀million฀in฀industrialised฀coun- tries.฀There฀were฀3.84฀million฀male฀deaths฀and฀1.00฀million฀female฀deaths฀associated฀with฀ smoking.฀The฀leading฀causes฀of฀death฀from฀smoking฀were฀cardiovascular฀diseases,฀COPD฀ and฀lung฀cancer฀ [44] . Table 2.4 ฀฀฀Numbers฀and฀percentages฀of฀smoking-related฀deaths฀in฀the฀former฀socialist฀countries฀ in฀1990 Country Men Women 35–69฀years 70฀years All฀ages 35–69฀ years 70฀years All฀ages Armenia 2.2฀38 0.5฀13 2.8฀23 0.2฀6 0.1฀1 0.3฀3 Azerbaijan 2.7฀24 0.5฀8 3.1฀14 0.0฀0 0.0฀0 0.0฀0 Belarus 1.0฀39 3.1฀16 14.1฀26 0.3฀2 0.1฀1 0.4฀1 Bulgaria 8.2฀30 2.2฀7 10.4฀17 0.5฀3 0.4฀1 0.9฀2 Czech฀Republic 13.3฀42 6.1฀19 19.4฀29 1.4฀9 1.5฀3 2.9฀5 Estonia 1.9฀38 0.5฀15 2.4฀26 0.2฀6 0.1฀2 0.3฀3 Georgia 2.8฀24 0.7฀9 3.5฀15 0.1฀2 0.1฀1 0.1฀1 Hungary 16.0฀41 6.5฀19 22.5฀29 3.1฀14 3.1฀7 6.0฀9 Kazakhstan 15.2฀43 3.7฀22 18.9฀28 2.3฀12 1.9฀6 4.2฀7 Kirghizstan 2.0฀28 0.7฀17 2.7฀17 0.2฀4 0.3฀5 0.5฀4 Latvia 3.3฀38 1.0฀15 4.3฀25 0.3฀6 0.3฀2 0.6฀3 Lithuania 3.8฀38 1.4฀17 5.2฀25 0.2฀3 0.4฀3 0.6฀3 Moldavia 3.5฀31 0.7฀10 4.3฀20 0.3฀3 0.3฀3 0.6฀3 Poland 44.6฀42 15.3฀18 59.9฀29 5.1฀10 4.4฀4 9.5฀5 Romania 19.6฀32 4.2฀8 23.8฀18 2.2฀6 0.8฀1 2.9฀3 Russia 191.9฀42 48.6฀20 240.5฀30 16.4฀7 19.3฀3 35.7฀4 Slovakia 5.8฀38 1.9฀15 7.7฀26 0.3฀4 0.4฀2 0.7฀3 Tadzhikistan 0.7฀14 0.2฀6 1.0฀5 0.0฀0 0.0฀0 0.0฀0 Turkmenistan 1.1฀22 0.2฀6 1.3฀9 0.0฀0 0.0฀0 0.0฀0 Ukraine 64.4฀40 19.5฀17 83.9฀28 5.9฀6 8.5฀4 14.5฀4 Uzbekistan 4.7฀20 0.9฀5 5.6฀8 0.7฀5 0.5฀2 1.3฀2 Yugoslavia 19.4฀36 6.3฀13 25.7฀23 2.0฀6 1.6฀2 3.6฀4 Total 441.2฀39 126.3฀17 567.5฀26 42.1฀7 44.4฀3 86.5฀4 Numbers฀of฀deaths฀in฀1,000s;฀percentages฀in฀parentheses฀ [43] 1955 1965 1975 1985 1990 1995 100 200 300 400 500 600 700 800 900 Annual Deaths x 1,000 Males Females Fig. 2.6 ฀฀฀Annual฀death฀rates฀ from฀lung฀cancer฀in฀men฀ and฀women฀in฀OECD฀ countries฀ [43] Smoking-related฀deaths฀in฀the฀industrialised฀countries฀will฀also฀continue฀to฀increase฀in฀ the฀coming฀years,฀a฀fact฀that฀is฀of฀course฀attributable฀to฀the฀huge฀increase฀in฀cigarette฀con- sumption.฀In฀the฀light฀of฀these฀developments,฀the฀WHO฀convened฀a฀conference฀back฀in฀ 1989฀ [1] .฀According฀to฀the฀data฀listed฀in฀Tables฀ 2.3 ฀and฀ 2.4 ,฀the฀number฀of฀smoking-related฀ deaths฀in฀1990฀was฀1.8฀million,฀and฀on฀this฀basis,฀a฀total฀of฀some฀20฀million฀deaths฀may฀be฀ assumed฀for฀the฀1990s.฀Males฀predominated฀numerically,฀but฀this฀pattern฀is฀set฀to฀change฀ in฀the฀coming฀years. The฀calculation฀of฀smoking-related฀mortality฀is฀dificult฀for฀the฀majority฀of฀developing฀ countries:฀a฀spectacular฀increase฀has฀been฀recorded฀in฀China฀in฀recent฀years,฀particularly฀ since฀smoking฀prevalence฀among฀men฀in฀that฀country฀has฀exceeded฀the฀50฀limit.฀The฀ incidence฀ of฀ illness฀ in฀ Asia฀ and฀ Latin฀ America฀ is฀ very฀ high฀ [40] .฀ Taking฀ all฀ countries฀ together฀ the฀ industrialised฀ plus฀ the฀ developing฀ countries,฀ 3฀ 2–4฀ million฀ people฀ die฀ annually฀from฀the฀consequences฀of฀cigarette฀smoking. Currently,฀there฀are฀2,300฀million฀children฀and฀teenagers฀in฀the฀world,฀of฀whom฀30–40฀ i.e.฀800฀million฀young฀people฀smoke.฀If฀smoking฀doubles฀in฀all฀age฀groups,฀this฀could฀ result฀in฀the฀death฀of฀50฀of฀all฀smokers฀ [43] . During฀the฀period฀1978–1992,฀cigarette฀production฀in฀China฀increased฀from฀500,000฀ million฀to฀1.7฀billion,฀and฀the฀cigarettes฀had฀very฀high฀tar฀values.฀Research฀in฀China฀into฀ the฀health-related฀consequences฀of฀this฀development฀lung฀cancer,฀COPD฀and฀oesophageal฀ cancer฀has฀already฀been฀conducted,฀but฀the฀results฀remain฀unpublished฀ [43] . According฀to฀extrapolations฀for฀the฀period฀2020–2030,฀it฀is฀estimated฀worldwide฀that฀ 3–10฀million฀deaths฀a฀year฀would฀be฀attributable฀to฀smoking฀ [43]

2.5 Other Forms of Tobacco Use

Cigar฀smoking฀has฀increased฀again฀in฀recent฀years฀in฀the฀belief฀that฀it฀represents฀a฀smaller฀ risk฀ than฀ cigarette฀ smoking฀ Fig.฀ 2.8 ฀ [45,฀ 46] .฀ Cigar฀ consumption฀ increased฀ by฀ 66฀ between฀1964฀and฀1993฀and฀by฀46.4฀between฀1993฀and฀1997฀ [46] .฀Consumption฀of฀ 1955 1965 1975 1985 1990 1995 100 200 300 400 500 600 700 Annual Deaths x 1,000 Males Females Fig. 2.7 ฀฀฀Annual฀death฀rates฀ from฀lung฀cancer฀in฀men฀and฀ women฀in฀the฀former฀ socialist฀countries ฀[43] large฀cigars฀and฀cigarillos฀increased฀by฀69฀between฀1993฀and฀1997฀ [47] .฀According฀to฀ research฀conducted฀in฀California,฀between฀1990฀and฀1996,฀more฀young฀adult฀male฀than฀ female฀high-school฀graduates฀preferred฀to฀smoke฀cigars฀ [48] ฀and฀this฀activity฀has฀since฀ overtaken฀smokeless฀tobacco฀use฀in฀the฀USA฀ [49] .฀Some฀young฀people฀also฀replace฀the฀ inner฀tobacco฀of฀the฀cigar฀with฀marijuana฀or฀other฀illegal฀drugs฀a฀practice฀known฀as฀ blunting฀ [50] . According฀to฀several฀studies,฀cigar฀smoking฀is฀perceived฀to฀be฀less฀dangerous฀than฀ cigarette฀smoking฀in฀terms฀of฀carcinogenicity฀ [51–53] .฀Aside฀from฀notions฀of฀reduced฀ carcinogenicity,฀however,฀differing฀smoking฀behaviours,฀duration฀of฀smoking,฀extent฀of฀ inhalation฀and฀age฀at฀smoking฀initiation฀must฀also฀be฀taken฀into฀account฀ [51,฀54,฀55] .฀ Overall,฀no฀studies฀have฀been฀conducted฀among฀larger฀numbers฀of฀smokers฀using฀tobacco฀ products฀other฀than฀cigarettes.฀According฀to฀a฀meta-analysis฀of฀seven฀studies฀involving฀ 7,200฀ controls฀ and฀ 5,600฀ male฀ smokers฀ pipe฀ and฀ cigar,฀ there฀ was฀ a฀ dose-dependent฀ increase฀in฀lung฀cancer฀risk,฀with฀cigarillo฀smokers฀having฀the฀same฀increased฀risk฀as฀ cigarette฀smokers฀odds฀ratio฀OR:฀12.7฀vs.฀14.7;฀cigarillo฀vs.฀cigarette฀ [56] ,฀obviously฀ a฀ consequence฀ of฀ the฀ inhalation฀ of฀ tobacco฀ smoke.฀ In฀ a฀ cohort฀ study฀ in฀ 17,774฀ men฀ between฀the฀age฀of฀30฀and฀85฀years,฀cigar฀smokers฀were฀also฀found฀to฀have฀an฀increased฀ risk฀of฀developing฀coronary฀heart฀disease฀OR฀1.27,฀COPD฀OR฀1.45฀and฀cancers฀of฀the฀ upper฀respiratory฀and฀gastrointestinal฀tract฀OR฀2.02.฀Cigar฀smokers฀clearly฀underesti- mate฀their฀cancer฀risk,฀with฀only฀7.8฀believing฀that฀cigar฀smoking฀will฀damage฀their฀ health.฀They฀also฀underplay฀the฀damage฀to฀the฀health฀of฀those฀around฀them฀as฀a฀result฀of฀ passive฀smoking฀ [57–59] . The฀use฀of฀other฀forms฀of฀tobacco฀is฀more฀common฀among฀men฀than฀women฀ [6,฀21] .฀ Snuff฀tobacco฀has฀been฀consumed฀increasingly฀during฀the฀last฀25฀years.฀A฀recently฀pub- lished฀study฀from฀Sweden฀indicates฀that฀taking฀snuff฀contributes฀to฀increased฀smoking.฀ U.S. Cigar Consumption Billions 1895 1875 1915 1935 1955 1975 1995 Year 2 4 6 8 10 12 14 Modern blended cigarettes introduced Great depression Final Surgeon General’s Report Ban on TV Advertising of little cigars Cigar Aficionado begins publishing Advertising of little cigars begins on TV Fig. 2.8 ฀฀฀Total฀U.S.฀cigar฀consumption฀1880–1997฀and฀signiicant฀events฀in฀the฀use฀of฀cigars฀ [45]