Tobacco and public health

The World Health Organization (WHO) estimates that there are about 1100 million smokers in the world, representing about one-third of the global population (Table 1). The vast majority of the smokers are in developing countries (800 million) and most of these are men (700 million). In China alone, there are about 300 million smokers (90% men, 10% women), about the same number as in all developed countries combined. About one-third of regular smokers in developed countries are women, compared with only about one in eight in developing countries.

Globally, it is estimated that 47% of men and 12% of women smoke (Table 2). In the developed countries, the corresponding figures are 42% for men and 24% for women. In developing countries, available data suggest that about 48% of men and seven percent of women smoke. Table 2 also provides estimates of daily smoking prevalence for each of the six WHO regions. Male smoking prevalence varies substantially among regions, from less than 30% in the African Region to 60% in the Western Pacific Region (largely as a result of the male smoking prevalence of 61% in China, the largest country in the region). Even among developed countries, patterns of male smoking prevalence are not uniform. In countries with established market economies, male smoking prevalence averages 37%, compared with 60% in the former socialist countries of Central and Eastern Europe.

Smoking among women is most prevalent in the former socialist countries of Central and Eastern Europe (28%), countries with established market economies (23%) and Latin American and Caribbean countries (21%). In most other countries, fewer than 15% of women smoke.

In many countries people begin smoking at younger and younger ages, with the median age of initiation under 15 in many countries. Moreover, the prevalence of smoking is frequently very high among younger people. For example, in South Africa, over 50% of young men under the age of 35 are smokers, while the proportion of young people aged 18-24 who smoke in both

France and Spain is over 40%. Starting to smoke at younger ages increases the risk of death from a smoking-related cause, and lowers the age at which death is likely to occur. Young people who start smoking early in life will often find it very difficult to quit smoking. Among those who continue to smoke throughout their lives, about one-half can be expected to die from a smoking-related cause, half of these in middle age (35-69 years) and the other half in old age (70 years and over). In countries such as South Africa, where more than 50% of young men are smokers, or France or Spain, where more than 40% of young people aged 18-24 smoke and most began at a young age, a very heavy future death toll from tobacco use can be expected.

In general, fewer cigarettes are smoked per day in developing countries (14) than in developed countries (22). Among developed countries, the highest rate of daily consumption per smoker, 24 cigarettes per day, occurs in countries with established market economies, while in the former socialist countries of Europe, the corresponding figure is 18 cigarettes per day, on average. In the regions, the number of cigarettes smoked by daily smokers ranges from a low of 10 per day in the African Region to a high of 18 per days in the Region of the Americas and the European Region. The rate shown for all developed countries, 22 cigarettes per smoker per day, is higher than that of any single WHO region. This is because all WHO regions include at least some developing countries, where daily consumption per smoker is usually lower than in developed countries.

However, developing countries can take little comfort from these data. One of the characteristics of tobacco addiction is that tolerance to nicotine increases over time. In response, smokers increase their intake to the extent that they can afford to smoke more cigarettes per day. In many developing countries, smoking has become widespread only in recent years. As large numbers of young smokers grow older, the daily consumption of cigarettes per smoker can be expected to increase. This trend towards increasing daily consumption per smoker will be accelerated where economic development results in increased real disposable personal income, unless effective tobacco control measures reduce demand.