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Review – Epidemiology

Global and Regional Patterns of Tobacco Smoking and Tobacco Control Policies

By: Farhad Islamia , Michal Stoklosab, Jeffrey Dropeb and Ahmedin Jemala

EU Focus, Volume 1 Issue 1, November 2015, Pages 3-16

Published online: 13 November 2015

Keywords: E-cigarettes, Global, Review, Smoking, Tobacco control

Abstract Full Text Full Text PDF (0,9 MB) Patient Summary

Abstract

Context

Tobacco smoking is a major worldwide cause of morbidity and mortality from various diseases, including urologic diseases.

Objective

We reviewed, at global and regional levels, the prevalence and trends of tobacco smoking and legislative and regulatory efforts around tobacco control. We also provided information about electronic cigarette (e-cigarette) use.

Evidence acquisition

We used several sources to present the most up-to-date information from national surveys, including the Global Adult Tobacco Survey, the Global Tobacco Control Report, and the Global Youth Tobacco Survey.

Evidence synthesis

Smoking prevalence has been decreasing globally, although trends in smoking vary substantially across countries and by gender. Among men, smoking prevalence in most high-income countries started to decrease in the mid-1990s, followed after a few decades by generally smaller decreases in some low- and middle-income countries (LMICs). However, there has been no change, or there has even been an increase, in smoking prevalence in many other LMICs. Countries with the highest male smoking prevalence are located in East Asia, Southeast Asia, and Eastern Europe. Similar to men, smoking prevalence for women has been decreasing in most high-income countries and some LMICs, although the decrease began later and was slower than that for men. Except in a few countries, smoking is much less common for women than for men. Most countries with the highest smoking prevalence in women are in Europe. Countries that have implemented the best practices for tobacco control, including monitoring, smoke-free policies, cessation programs, health warnings, advertising bans, and taxation, have been able to reduce smoking rates and related harms. E-cigarette use has rapidly increased since its introduction to the market.

Conclusions

Health care providers should advise smoking patients about quitting smoking. Countries must improve the implementation and enforcement of tobacco control policies. Particular attention should be paid to preventing an increase in smoking among women in LMICs.

Patient summary

We reviewed smoking prevalence and tobacco control policies in various regions. Countries with more effective tobacco control programs have seen higher reductions in smoking prevalence and, consequently, in smoking-related mortality. Because both longer duration and higher intensity of smoking (amount of tobacco smoked per day) are associated with an increased risk of tobacco-related diseases, smokers should quit smoking as soon as possible.

Take Home Message

Smoking prevalence has been decreasing globally, but smoking rates are still high in many countries, particularly in Asia, Southern Europe, and Eastern Europe. Health care providers should advise smoking patients about quitting smoking. More research on e-cigarettes as a smoking cessation tool and on their long-term health effects is required.

Keywords: E-cigarettes, Global, Review, Smoking, Tobacco control.

1. Introduction

The epidemic of tobacco-related diseases is the first worldwide epidemic created by humans. Tobacco use killed 100 million people globally in the 20th century and will kill 1 billion in the 21st century if current patterns persist [1] and [2]. Tobacco use is also a burden on global economic development. In the United States alone, the estimated economic cost related to tobacco consumption is $289 billion per year [3].

Tobacco use is a known risk factor of cancer and other diseases in a number of organs. Although tobacco use has some short-term health effects, tobacco-related mortality usually peaks a few decades after smoking [4]. Therefore, knowing patterns of tobacco smoking not only helps to understand the current epidemiology of smoking-related diseases but also can provide valuable information about the epidemiology of these diseases in the future.

In this review, we provide information on prevalence and trends of tobacco smoking at global and regional levels. We also briefly review the use of electronic cigarettes (e-cigarettes), which has been rapidly growing. Finally, we discuss legislative and regulatory efforts around tobacco control and their effects on smoking patterns.

2. Evidence acquisition

We used several sources of smoking data to present the most up-to-date information from national surveys. For current regular smoking, we used the Global Adult Tobacco Survey (GATS), an international survey using the same protocol across the surveys, as the main source of national data [5]. When data for specific countries were not available from this survey, we used the World Health Organization (WHO) Report on the Global Tobacco Epidemic 2013 (also known as the Global Tobacco Control Report [GTCR]), which collected data (up to 2012) from various sources [6]. We also used a subnational survey [7] and a few national surveys [8], [9], [10], [11], [12], [13], [14], [15], and [16] for more recent smoking data that were not included in GATS or the GTCR, as well as for information on e-cigarettes [8], [17], [18], [19], [20], [21], [22], and [23]. For daily smoking data, we used the estimated prevalence presented in a publication from the Institute for Health Metrics and Evaluation (University of Washington, Seattle, WA, USA) [24]. Although the main focus of this review is smoking in adults, we used data from the Global Youth Tobacco Survey, an international survey on youth tobacco use [5] and [25], to show data on youth tobacco use. We also briefly discuss smokeless tobacco use even though its associations with urologic diseases are not well established, because it is the most common form of tobacco use in certain countries.

Throughout this article, tobacco smoking refers to smoking of any tobacco product (cigarette, cigar, cigarillo, hookah, bidi, or any other product), unless stated otherwise. To combine data and show trends of smoking prevalence from 1980 to 2012 and current coverage of tobacco policies by continents, we used the United Nations (UN) list of countries in each continent [26]. This list is slightly different from some commonly used lists: Armenia, Azerbaijan, Cyprus, Georgia, and Turkey are considered West Asian rather than European countries. Nevertheless, we used this official UN list, and this difference did not substantially change the trends/coverages in continents. The only exception to using the UN list was when we showed smoking rates for individual countries. From the above West Asian countries in the UN list, smoking rates were shown for Cyprus and Turkey, both of which are listed among European countries in Table 1. We used the World Bank databases to obtain countries’ populations and income groups [27]. Income groups were defined by annual gross national income per capita as low, ≤$1045; lower middle, $1046–$4125; upper middle, $4126–$12 745; and high, ≥$12 746.

Table 1

Prevalence of current tobacco smoking in national surveys in selected countries by continent*

Country by continentPopulation, millions, 2013Income groupYearAge group, yrMale, %Female, %Total, %
AFRICA
East Africa
Kenya [6]44.4Low2008–200915–5420.0
Malawi [6]16.4Low200925–6425.92.914.1
Rwanda [6]11.8Low201015–59a16.13.6
Tanzania [9]49.3Low201215–4920.00.6
Uganda [6]37.6Low201115–59a15.72.8
North Africa
Algeria [6]39.2Up-mid201015–7427.11.715.3
Egypt [5]82.1Lo-mid2009≥1537.70.519.4
Libya [6]6.2Up-mid200925–6449.60.8
Morocco [6]33.0Lo-mid2006≥1831.53.318.0
Central Africa
Cameroon [6]22.3Lo-mid2003≥1512.72.06.3
Chad [6]12.8Low200825–6420.21.211.2
Gabon [6]1.7Up-mid200915–6421.04.6
Sao Tome and Principe [6]0.2Lo-mid200925–649.71.75.5
Southern Africa
Botswana [6]2.0Up-mid200725–6432.87.819.7
South Africa [10]53.0Up-mid2012≥1532.8b10.1b20.8b
Swaziland [6]1.2Lo-mid200725–6412.92.27.1
West Africa
Benin [6]10.3Low200825–6415.81.78.7
Ivory Coast [6]20.3Lo-mid201215–4926.21.7
Ghana [6]25.9Lo-mid200815–59a8.20.44.2
Niger [6]17.8Low200715–648.71.0
Nigeria [5]173.6Lo-mid2010≥1510.01.15.6
Sierra Leone [6]6.1Low200925–6443.110.525.8
AMERICAS
North America
Canada [11]35.2High2012≥1518.413.916.1
United States [8]316.1High2012–2013≥1822.614.919.2
Caribbean
Cuba [6]11.3Up-mid2010≥1531.116.423.7
Dominican Republic [6]10.4Up-mid2003≥1817.212.514.9
Jamaica [6]2.7Up-mid201115–7422.9c7.5c15.1c
Trinidad and Tobago [6]1.3High201115–6433.5c9.4c21.1c
Central America
Costa Rica [6]4.9Up-mid201018–7018.65.812.8
El Salvador [6]6.3Lo-mid200512–6521.53.411.7
Mexico [5]122.3Up-mid2009≥1524.87.815.9
Panama [5]3.9Up-mid2013≥159.42.86.1
South America
Argentina [5]41.4Up-mid2012≥1529.415.622.1
Brazil [5]200.4Up-mid2008≥1521.613.117.2
Chile [6]17.6High2010≥1544.237.140.6
Paraguay [6]6.8Lo-mid201115–7422.86.114.5
Uruguay [5]3.4High2009≥1530.719.825.0
Venezuela [6]30.4Up-mid201118–6528.914.421.5
ASIA
East Asia
China [5]1357.4Up-mid2010≥1552.92.428.1
Japan [6]127.3High2011≥2032.49.720.1
Mongolia [6]2.8Lo-mid200915–6448.06.927.7
South Korea [6]48.6High2011≥2047.36.827.0
Southeast Asia
Cambodia [6]15.1Low2011≥1539.13.419.5
Indonesia [5]249.9Lo-mid2011≥1567.02.734.8
Malaysia [5]29.7Up-mid2011≥1543.91.023.1
Philippines [5]98.4Lo-mid2009≥1547.79.028.3
Singapore [6]5.4High201218–6927.9c5.0c16.3c
Thailand [5]67.0Up-mid2011≥1546.62.624.0
Vietnam [5]89.7Lo-mid2010≥1547.41.423.8
South and Central Asia
Bangladesh [5]156.6Low2009≥1544.71.523.0
India [5]1252.1Lo-mid2009–2010≥1524.32.914.0
Kazakhstan [6]17.0Up-mid200715–6548.012.129.8
Kyrgyzstan [6]5.7Lo-mid2005≥1545.01.621.8
Nepal [6]27.8Low201115–4951.913.3
Pakistan [12]182.1Lo-mid2010–2011≥4030.1b2.0b18.7b
Sri Lanka [6]20.5Lo-mid200615–6429.90.415.0
Uzbekistan [6]30.2Lo-mid2006≥1520.01.110.0
West Asia
Iran [6]77.4Up-mid200915–6424.63.314.1
Iraq [6]33.4Up-mid2007≥1226.52.914.8
Jordan [6]6.5Up-mid2007≥1849.6b5.7b29.0b
Kuwait [6]2.9High200620–6442.34.437.8
Lebanon [6]4.5Up-mid201018–10043.233.838.2
Oman [6]3.6High2008≥1814.70.27.0
Qatar [5]2.2High2013≥1520.23.112.1
EUROPE
Eastern Europe
Bulgaria [13]7.3Up-mid2012≥15423136
Hungry [13]9.9Up-mid2012≥15372832
Latvia [13]2.0High2012≥15522236
Poland [5]38.5High2010≥1536.824.430.3
Romania [5]20.0Up-mid2011≥1537.416.726.7
Russia [5]143.5High2009≥1560.221.739.1
Ukraine [5]45.5Lo-mid2010≥1550.011.228.8
Southern Europe
Cyprus [13]1.1High2012≥15421930
Greece [5]11.0High2013≥1551.225.738.2
Turkey [6]74.9Up-mid2012≥1541.413.127.0
Western Europe
Austria [13]8.5High2012≥15402633
Belgium [13]11.2High2012≥15302427
Finland [13]5.4High2012≥15282225
France [13]66.0High2012≥15312628
Germany [13]80.6High2012≥15322226
Ireland [13]4.6High2012≥15283029
Italy [13]59.8High2012≥15282124
Netherlands [13]16.8High2012≥15281924
Norway [6]5.1High201116–7428.028.028.0
Spain [13]46.6High2012≥1540.026.033.0
United Kingdom [14]64.1High2012≥1622.019.020.0
OCEANIA
Australia [15]23.1High2013≥1418.313.415.8
New Zealand [16]4.5High2012–2013≥1518.716.417.6
Papua–New Guinea [6]7.3Lo-mid200715–6460.327.044.0
Tonga [6]0.1Up-mid200615–6445.912.028.8

* Smoking any tobacco products (excludes smokeless tobacco use). Current smoking was defined as current daily smoking or occasional smoking (less than daily smoking) in the Global Adult Tobacco Survey [5]. This group included every day and someday smokers in the US survey and current smokers of “any amount” in the Iranian survey. Population and income group data are from the World Bank.

a Men aged 15–59 yr and women aged 15–49 yr.

b Ever smoking (current or former smoking).

c Only cigarette smoking.

Lo-mid = lower-middle income; Up-mid = upper-middle income.

3. Evidence synthesis

3.1. Global patterns of tobacco smoking

Recent estimates suggest that in 2012, 928 million men and 207 million women were current smokers of any tobacco product globally [28], and the majority (807 million men and 160 million women) were daily smokers [24]. Most countries with the highest male smoking prevalence are in East Asia, Southeast Asia, and Eastern Europe. The highest female smoking rates are mostly in European countries.

3.1.1. Tobacco epidemic

Trends in smoking prevalence in most high-income countries have followed a pattern that is commonly termed the tobacco epidemic or the cigarette epidemic[4] and [29]. In this model, smoking prevalence first increases among men, followed by an increase in women. Smoking-related cancer mortality starts to increase substantially after approximately three to five decades (Fig. 1) [4] and [30].

gr1

Fig. 1

Estimated cigarette smoking prevalence and tobacco-related deaths in the United States, 1900–2012 [8] and [35].

The estimated age-standardized smoking prevalence in men and women has been decreasing on all continents (Fig. 2). From 1980 to 2012, smoking rates in both men and women substantially decreased in Oceania and the Americas, chiefly in New Zealand, Australia, and North America. In Europe, although male smoking has also substantially decreased, female smoking has started to show a modest decrease only recently. In Asia, male smoking rates were increasing in the 1980s and started to decrease in the mid-1990s; nevertheless, the smoking prevalence in men was >35% in 2012, the highest of all continents. The smoking prevalence in African men has been lower than that of men in other continents. Smoking by women in Africa and Asia has been traditionally low (chiefly <5%) and changed little from 1980 to 2012. As male smoking in many African countries and female smoking in many low- and middle-income countries (LMICs) have not yet followed the tobacco epidemic pattern, a major priority for health authorities in LMICs must be to prevent a surge in smoking similar to what happened in high-income countries.

gr2

Fig. 2

Estimated age-standardized daily smoking prevalence in (a) men and (b) women (aged ≥15 yr) by continent (age-standardized to the 2000 world standard population) [24].

3.1.2. Duration and intensity of smoking

Increased harm from smoking is associated with longer duration of smoking, higher smoking intensity (the average number of cigarettes smoked per day) [31], and greater nicotine dependency (measured by time to first cigarette after waking) [32] and [33]. When smoking prevalence is high, the mean initiation age is generally <20 yr [3] and [34]. Those who start smoking at earlier ages are generally exposed to smoke for longer durations, unless they quit early [35]. Before the tobacco epidemic starts in a population, the mean age of initiation is usually higher than after the epidemic is established; in the United States, for example, the mean initiation age was 35 yr among women born in 1900 and <20 yr in women born in 1940 and afterward [36]. Smoking initiation in earlier ages, an increase in smoking intensity, or a combination of both can substantially increase the magnitude of associations between smoking and diseases in a population over time. For example, the relative risk of lung cancer in women associated with current smoking in the United States increased from 2.7 to 12.7 to 25.7 in cohorts in the 1960s, 1980s, and 2000s, respectively [35].

Patterns of smoking intensity vary across countries. In some Latin American countries, including Chile and Bolivia, smoking intensity has remained relatively low (average <10 cigarettes per day) despite high smoking prevalence in those countries [24]. In contrast, average smoking intensity increased dramatically in China, from 15 cigarettes per day in 1980 to 22 cigarettes per day in 2012 [24]. The latter pattern might be seen more commonly in LMICs as a result of increases in income and/or broader cigarette affordability. In some countries that have managed to reduce smoking prevalence through successful tobacco control polices, such as Canada, Denmark, Iceland, New Zealand, and Uruguay, persons who continue to smoke are usually heavy smokers [24]. These intense tobacco users, who are at a higher risk of smoking-related diseases, may need more sustained help from health professionals to quit or at least reduce intensity of smoking.

3.1.3. Socioeconomic status and smoking

Increases in smoking prevalence in both men and women in high-income countries started mainly in higher socioeconomic groups [37] and [38]. Over time, high smoking prevalence shifted to lower socioeconomic groups as evidence about the health effects of smoking emerged in the 1950s and early 1960s [38]. In the United States, for example, smoking prevalence in 1940 was 36% in those with less than a high school education and 40% in people with education levels of college and above [38]; the corresponding rates were 35% and 13% in 2009–2010 [39]. Similar patterns of smoking prevalence by socioeconomic status have been reported in LMICs [40], [41], and [42]. When specific ethnic groups show high smoking prevalence, it is likely because they are disproportionately represented in lower socioeconomic groups [16] and [43].

3.2. Regional patterns of tobacco smoking

3.2.1. Africa

Updated information on tobacco smoking in Africa is limited [44], but similar to other LMICs, in Africa smoking is substantially more common among men than women (Table 1). The slight decrease in prevalence of daily smoking from 1980 to 2012 (Fig. 2) was chiefly prominent in countries in which the tobacco epidemic started earlier and had relatively higher smoking rates (eg, South Africa, Lesotho, Madagascar, and Algeria) [24]. In parallel with rapidly growing incomes, which often make cigarettes more affordable [45], and without major tobacco control interventions, it has been projected that the prevalence of current smoking will increase from 15.8% in 2010 to 21.9% in 2030 in the WHO African region (Africa excluding Djibouti, Egypt, Libya, Morocco, Somalia, Sudan, and Tunisia) if current trends continue [46]. Most of this increase is expected to be among men.

The consequences of the tobacco epidemic in Africa will be exacerbated by rapid population growth, which, although slowing, is among the highest in the world. By current trends, the estimated population of Africa will increase from 1.2 billion in 2015 to 1.7 billion in 2030 and to 4.2 billion (or 40% of the world's population) in 2100, with the highest increase in East Africa and West Africa [47]. Without appropriate tobacco control policies, including prevention strategies across the continent, Africa will lose many millions of lives in this century due to tobacco smoking [45].

3.2.2. The Americas

Smoking prevalence in Canada and the United States has decreased from >55% in men in the 1950s and >35% in women in the 1970s and 1980s [4] and [48] to <20% in men and <15% in women in 2012 (Table 1). Also, the daily smoking prevalence decreased by approximately 60% in both men and women in Mexico from 1980 to 2012 [24]. Several Caribbean, Central American, and South American countries have reduced smoking rates, though to a lesser degree and chiefly in men. However, there has been no significant change in male smoking in a few countries, including Chile, Costa Rica, Jamaica, Peru, and Suriname [24]. Smoking is generally less prevalent in Central America than in South America, particularly among women. The smoking prevalence in many South American countries is approximately 20–30% in men and 10–20% in women [6]. The highest smoking prevalence in South America is in Chile: 44.2% in men and 37.1% in women in 2010 (Table 1).

3.2.3. Asia

Approximately 60% of the world's current smokers in 2010 through 2012 lived in three Asian countries: China (317 million smokers), India (122 million smokers), and Indonesia (115 million smokers) [49]. Chinese men smoke one in every three cigarettes smoked worldwide [2]. In only a few Asian countries (eg, Kazakhstan, Lebanon, and Nepal) is the smoking prevalence in women >10% (Table 1). In contrast, smoking is quite common among Asian men. The male smoking prevalence is >40% in western parts of the Middle East (eg, Lebanon, Jordan, and Kuwait) but is lower (15–30%) in other West Asian countries (eg, Iran, Qatar, and Oman) and adjacent countries in South Asia and Central Asia (eg, India, Pakistan, and Uzbekistan). Moving toward the north and east, this rate increases to >40% in other South Asian and Central Asian countries (eg, Bangladesh, Kazakhstan, Kyrgyzstan, and Nepal).

Smoking prevalence in men is extremely high in many East Asian and Southeast Asian countries. The current smoking prevalence among men in 2010–2011 was 67% in Indonesia and 53% in China (Table 1). Some countries in East Asia and Southeast Asia have been able to reduce smoking rates. For example, male smoking rates halved in Hong Kong (China), Japan, and Singapore from 1980 to 2012 [50]. Nevertheless, many other countries need to implement more effective tobacco control policies to attain similar goals. With current high smoking rates in this highly populated region, smoking will be the main cause of morbidity and mortality for several decades. Current trends suggest that smoking will kill >50 million people between 2012 and 2050 in China alone [51].

3.2.4. Europe

Smoking rates have substantially decreased in several countries in Western Europe and Northern Europe, notably in the United Kingdom and the Nordic countries [24]. In the United Kingdom, smoking rates dropped from >80% in men in 1950 and approximately 40% in women in 1970 [52] to approximately 20% in both sexes in 2012 (Table 1). Although smoking rates have also started to decrease in many other European countries, the rates are still very high in Eastern Europe and Southern Europe (Table 1).

The tobacco epidemic started much earlier in Western Europe than in Eastern Europe. Following an earlier decline in male smoking prevalence, tobacco-related mortality in men is decreasing in several Western European countries [53]. A decline in smoking-related mortality in women has begun in countries with decreases in female smoking, including the United Kingdom [53]. High smoking-related morbidity and mortality are expected for at least several decades more in the European countries that now have high smoking prevalence.

3.2.5. Oceania

Two of the wealthiest countries in Oceania, Australia and New Zealand, have been quite successful in reducing smoking prevalence in both men and women, from >30% in the 1980s to <18% in 2013 in men and women combined [15] and [54]. However, similar to the smoking pattern in Southeast Asia, the male smoking prevalence in most other countries on this continent (eg, Papua–New Guinea and Tonga) is high (Table 1).

3.3. Blond and black (dark) tobacco

Blond tobacco is flue-cured tobacco that is high in sugar and produces a milder, more inhalable smoke compared with black (dark) tobacco. More than 90% of cigarettes smoked globally in 2013 were Virginia or American blended cigarettes [55], both of which are blond tobacco. Black tobacco is chiefly smoked in Latin America, Spain, and France [56] and is processed with open-air curing or air curing in barns with no or limited artificial heat. The strong varieties are usually used to make cigars, while light varieties are used in some cigarette blends in the countries above. With blond tobacco being more popular among smokers globally, black tobacco use is decreasing [57]. For example, the share of black tobacco in the tobacco market in Peru decreased from 17.6% in 2000 to 1.5% in 2009; the respective decrease in Spain was from 23.5% to 9.2% [57].

The few laboratory studies that exist on potentially carcinogenic compounds in black and blond tobacco and their effects on the human body have shown higher concentrations of N-nitrosamine and 2-napthylamine in black tobacco and higher urine mutagenicity and blood DNA adduct levels in black tobacco smokers [56] and [58]. However, the clinical significance of these differences is unclear.

3.4. Tobacco products other than cigarettes

Cigarettes are the most common smoking product worldwide. However, there are other tobacco products that are relatively commonly used in some populations. Water pipe (hookah) smoking has traditionally been common in the Middle East and North Africa and in some parts of Southeast Asia [59]. Water pipe use has increased among young people, particularly college students, in Europe and North America [59] and [60]. In the United States, for example, 7–20% of college students [61] and 5.4% of high school students [62] reported past-year/current water pipe use. The use of bidi (tobacco flakes wrapped in a leaf of the tendu or temburni tree), a relatively inexpensive tobacco product, is common in South Asia, in particular in low-income groups [5]. In India, bidi is the most commonly used smoking product (prevalence: 9.2%), followed by cigarettes (5.7%), water pipes (0.9%), and other products (1%) [5].

Global consumption of roll-your-own (RYO) tobacco increased by 45% from 2000 to 2013, with approximately 101 billion RYO cigarettes smoked worldwide in 2013 (compared with nearly 6 trillion regular cigarettes). Approximately 86% of RYO cigarettes were smoked in the European Union, where RYO cigarettes were much cheaper than regular cigarettes [63]. Global consumption of cigars and cigarillos (a cigarillo is a smaller, narrower version of a cigar) has not changed since the late 2000s and is approximately 24 billion per year, nearly half of which are smoked in the United States [63]. All smoking tobacco products are included in the smoking rates shown in this article, unless stated otherwise.

Smokeless tobacco use is common in South Asia, Central Asia, the Nordic countries, and Africa (Supplementary Table 1). For example, smokeless tobacco use in India is more common than smoking: 32.9% of men and 18.4% women are smokeless tobacco users [5]. Among children aged 13–15 yr in South Asia, Central Asia, the Middle East, and Africa, the use of tobacco products other than cigarettes is more common than cigarette smoking [5].

3.5. E-cigarettes

3.5.1. What is an e-cigarette?

Electronic cigarettes (e-cigarettes), also called electronic nicotine delivery systems (ENDS), are battery-powered devices that vaporize a liquid solution called e-liquid using a heating element known as an atomizer[64]. E-liquid generally contains nicotine, propylene glycol, vegetable glycerin, and various additives [64]. E-cigarette smokers inhale the resulting aerosol, which some say gives the feeling of cigarette smoking. E-cigarettes are produced with various features (eg, nonrefillable or refillable), but many of these products resemble cigarettes.

As e-cigarettes do not include combustion, their potential to deliver nicotine to users in a safer way than regular cigarettes and to aid tobacco smokers in quitting are of high interest; however, significantly more research is necessary to evaluate this potential rigorously. While two randomized controlled clinical trials have shown modest effectiveness of e-cigarettes in helping smokers to quit [65] and [66], two longitudinal epidemiological studies have not shown such a benefit at the population level [64] or in cancer patients [67]. In addition to research on e-cigarettes as a smoking cessation tool, there is a crucial need for more analysis on the long-term health effects of e-cigarette use [64], particularly because propylene glycol and other compounds in e-liquids may expose e-cigarette users to increased levels of toxic chemicals [68] and [69]. Also, nicotine is an addictive substance, and e-cigarette initiation by nonsmokers may eventually lead to their taking up traditional cigarettes [70]. For these reasons, regulations have been recommended by some health authorities to reduce the initiation of e-cigarette smoking in nonsmokers (see section 3.7, Regulating e-cigarettes).

3.5.2. Prevalence of use

As e-cigarettes have been marketed only recently, their prevalence of use is generally much lower than cigarette smoking (Table 2). However, a substantial increase in e-cigarette smoking in a short period has been reported in North American and European countries. For example, ever e-cigarette use among students in grades 6–12 in the United States increased from 3.3% in 2011 to 11.9% in 2013; the corresponding increase in current (past month) e-cigarette use was from 1.1% to 4.5% [23]. Ever use of e-cigarettes in the French population aged ≥15 increased from 7% in 2012 to 18% in 2013 [18]. In 2012, 1% of people in France reported regular or occasional use of e-cigarettes [13], but in 2013, 6% had used e-cigarettes in the last month [18]. Similar increases have likely occurred since 2012 in many countries in the European Union, in which a survey by the European Commission reported that the prevalence of ever use of e-cigarettes varied from 2% in Sweden to 14% in Belgium [13].

Table 2

Prevalence of e-cigarette smoking in adults and youth.

CountryYearAge groupEver use, %Current use, %
Adults
Canada [17]201216–30 yr16.15.7
France [18]2013≥15 yr186
Italy [19]2013≥15 yr6.81.2
Spain (Barcelona only) [7]2013–2014≥16 yr6.51.6
United States [8]2012–2013≥18 yr4.2a1.9
Youth
Canada [17]201216–19 yr12.52.6
France [18]201315–24 yr317
Poland [20]201115–19 yr23.58.2
South Korea [21]2011School grade 7–1219.74.7
United Kingdom [22]201311–15 yr41
16–18 yr102
United States [23]2013School grade 6–83.01.1
School grade 9–1211.94.5

a Every day, someday, or rarely users.

One of the primary concerns of e-cigarette use is how it affects cigarette use. E-cigarette use may not be an issue of concern if it occurs only in current smokers and only if it led to smoking cessation or at least a substantial decrease in smoking intensity. However, e-cigarette smoking in nonsmokers, or in current or former smokers, that might result in a maintenance (with no substantial decrease in smoking intensity) or surge in tobacco use is an issue that may need preventive measures. Cigarette smokers should be strongly encouraged to quit smoking using any evidence-based methods, with or without nicotine replacement therapy.

3.6. Tobacco control policies

3.6.1. MPOWER measures

Tobacco control policies reduce tobacco use and related harm. Because earlier policies usually were sporadic and isolated and could not prevent the global tobacco epidemic, in 2003 the World Health Assembly adopted the WHO Framework Convention on Tobacco Control (WHO FCTC), the first international treaty negotiated under the auspices of WHO, although the WHO FCTC did not come into force until 2005 [71]. In 2008, WHO identified six effective evidence-based measures for reducing tobacco use and began promoting them under the acronym MPOWER [6]. In 2011, UN member states committed to reduce premature mortality from noncommunicable diseases (a 25% reduction from 2010 levels by 2025) by addressing their major risk factors, including a 30% relative reduction in prevalence of current tobacco use in persons ≥15 yr [72].

The worldwide coverage of MPOWER policies is briefly described in the following sections and is summarized in Table 3 (percentage of countries with coverage) and Supplementary Table 2 (median levels of coverage). It should be noted that tobacco control policies might vary within countries in which jurisdiction is subnational for some policies and/or regulations. In the United States, for example, the northeastern and western states have generally been more successful in tobacco control than the southern states [53].

Table 3

Percentage of countries covered by tobacco control policies at World Health Organization–recommended levels, 2012.

Geographical regionM MonitoringP Smoke-free policiesO Cessation programsW WarningsE Advertising bansR Taxation
Health warningsMass media
By continent, %
Africa71101115204
Americas203817341796
Asia27241719271313
Europe642012219554
Oceania1925131325130
By income group, %
High income6222251325541
Upper-middle income22361124221915
Lower-middle income12172141882
Low income390912213

Source: World Health Organization Global Tobacco Control Report [6].

3.6.1.1. Monitoring tobacco use and prevention policies

Monitoring tobacco use and prevention policies is necessary to assess the effectiveness of current policies and the need for any policy modifications. Tobacco monitoring has traditionally been better in countries with developed health surveillance systems, including Australia, Canada, the United States, and most EU member states. Broader initiatives such as the Global Tobacco Surveillance System Surveys [5], which provide funding and training from high-income countries (notably from the US government and private foundations), can help improve tobacco monitoring in LMICs.

3.6.1.2. Protecting people from tobacco smoke

As exposure to secondhand smoke is harmful [73], smoking in public places has been banned to some degree in many countries. In 2012, however, only 16% of the world's population was covered by comprehensive smoke-free laws [6], demonstrating the need for improved implementation and/or enforcement of these laws. Middle-income countries are the best covered with smoke-free policies, with South America being the leading region in implementation [6].

Smoking in cars [74], outdoor places [75], and multiunit buildings [76] can also be sources of exposure to secondhand smoke. A few countries, including Bahrain, Cyprus, Mauritius, South Africa, and United Arab Emirates, as well as several states or provinces in Australia, Canada, and the United States, have banned smoking in vehicles carrying children, and several other countries are considering similar bans [77], [78], and [79].

3.6.1.3. Offering help to quit tobacco use

Personalized advice from health professionals [80] and access to affordable nicotine replacement therapies [81] help patients quit smoking. In many successful tobacco control strategies, cessation support by health care providers is accompanied by quit lines and other communication technologies such as appropriate text messaging, social networking, and phone applications [82], [83], and [84]. These policies are best implemented in the wealthiest nations. Of 55 high-income countries in 2012, 47 countries fully covered at least one of the policies (cessation service or nicotine replacement therapy), and 14 countries covered both policies [6].

3.6.1.4. Warning about the dangers of tobacco

A large share of the world's population still is not fully aware of the health risks associated with tobacco use: <40% of adults in China believe that smoking causes heart attacks, and <50% of adults in India believe that smoking causes strokes [5]. Harms of tobacco can be communicated through antitobacco campaigns and health warnings on tobacco product packages. Media campaigns can quickly reach large populations of both smokers and nonsmokers.

Health warning labels are most effective in the form of large pictures [85] located on the upper part of both the front and rear panels of each cigarette package. Middle-income countries are the highest-achieving country group in implementing large pictorial warning labels. The new EU Tobacco Products Directive makes using such labels mandatory in all EU member states by May 2016 [86]. It has been shown that tobacco warning labels work best when they elicit disgust, fear, or sadness [87].

3.6.1.5. Enforcing bans on tobacco advertising, promotion, and sponsorship

Marketing bans protect people from alluring industry messages aimed at discouraging existing smokers from quitting and attracting new smokers, especially youth [88]. There are now 127 countries (with 74% of the world's population) that ban all or almost all forms of direct and indirect tobacco advertising [6]. Low-income countries are the best group in implementing these policies.

To limit the effect of appealing tobacco packages, an innovative plain packaging law was introduced in December 2012 in Australia to standardize the size, labeling, and shape of packages. For example, this law requires that brand and company names on all retail tobacco packs in Australia must be printed in a uniform, small-sized font, and packs must have a drab dark brown color [89]. Preliminary studies have reported a boost in the number of quit line calls following the introduction of this law [90] and no increase in the availability of illicit tobacco, which contrasted the tobacco industry's claims and arguments [91]. In 2015, Ireland and the United Kingdom also passed plain packaging legislations [92].

3.6.1.6. Raising tobacco taxes

Tobacco excise tax increases that result in higher tobacco product prices are among the most effective tobacco control measures available, particularly to reduce smoking rates in youth and lower socioeconomic groups [93] and [94]. Tax rates need to be regularly revised to increase the price of tobacco products at a rate above inflation and income growth, making tobacco products less affordable over time [95]. With a successful cigarette tax harmonization and integration regimen in the European Union, the member states have the highest tobacco excise taxes in the world [96]. In the United States, where tobacco taxes are partly set by states, the tobacco tax in northeastern states is higher and in southern states is lower than in the rest of the country; higher taxes are associated with lower smoking prevalence in states [97].

In addition to decreasing tobacco use prevalence and intensity, tobacco tax increases generate sizable revenues, which can be used to fund tobacco control and other public health initiatives. For example, Costa Rica and the Philippines use a major portion of their revenues from recent cigarette tax increases in health care, including the diagnosis, treatment, and prevention of tobacco-related diseases [6] and [98]

3.6.2. The need for comprehensiveness in tobacco control policies

Tobacco control policies need to be comprehensive and include all tobacco products. Otherwise, smokers may just substitute one product for another. In Poland, for example, following a cigarette excise tax increase in January 2004, sales of manufactured cigarettes declined while sales of tobacco for RYO cigarettes increased (from a cigarette equivalent of 3.4 billion in 2003 to 5.7 billion in 2004). When tax rates were increased on both manufactured and RYO cigarettes in January 2005, pipe tobacco sales increased from a cigarette equivalent of 0.2 billion in 2004 to 2.0 billion in 2005 and 3.3 billion in 2006 [99].

3.6.3. Lobbying and litigation

More than 85% of all cigarettes smoked globally are being produced by only six transnational companies: China National Tobacco Corporation, Philip Morris International, British American Tobacco, Japan Tobacco International, Imperial Tobacco Group, and Altria Group [63]. Each of these companies has a gross revenue that is comparable to the gross domestic product of a small country [2]. These companies frequently lobby or challenge tobacco control proposals legally to block or delay their implementation. Examples include a multimillion-dollar lobbying campaign to undermine the revision of the EU Tobacco Products Directive [100] and a challenge to Australia's plain packaging regulations in domestic courts, at the World Trade Organization, and in international arbitration as part of a bilateral investment treaty [101] and [102]. In contrast, governments, health organizations, and individuals in several countries have sued the tobacco industry for violating tobacco control regulations and for the health and environmental consequences of their products and practices [103] and [104].

3.7. Regulating e-cigarettes

How to regulate e-cigarettes is a matter for debate and research. Regulatory objectives for e-cigarettes recommended by WHO include impeding ENDS promotion to and uptake by nonsmokers, pregnant women, and youth; minimizing potential health risks to ENDS users and nonusers; prohibiting unproven health claims from being made about ENDS; and protecting existing tobacco control efforts from commercial and other vested interests of the tobacco industry [105]. Some authorities have already taken steps to regulate e-cigarettes. For example, within the provisions of the revised EU Tobacco Products Directive, the amount of nicotine in e-cigarettes and refill containers will be limited, products will be required to carry health warnings, and e-cigarette advertising will be banned (unless approved for advertising as a smoking cessation device) in all 28 EU member states by May 2016 [86]. In the United States, in contrast, the US Food and Drug Administration (FDA) now has no authority to regulate e-cigarettes. Although the FDA proposed a new rule in April 2014 to extend its authority to e-cigarettes, including some basic measures such as bans on e-cigarette sales to minors or on the distribution of free samples, implementation of any regulation of e-cigarettes, if adopted, may take several years [106].

3.8. Investing in tobacco control

Few public health investments provide greater dividends than tobacco control. Countries that have implemented the best practices reflected in the WHO FCTC are now benefiting from their actions. For example, since 1989, Brazil has reduced its smoking rates by close to half through several tobacco control initiatives. It is estimated that those combined policies averted 420 000 deaths by 2010, more than half of which were because of cigarette tax increases [107]. The comprehensive tobacco control policies that were implemented globally from 2007 to 2010 alone prevented an estimated 7.5 million smoking-related deaths [108].

Tobacco control interventions are relatively inexpensive to implement. WHO estimates that delivering four population-based tobacco control measures (tobacco tax increases, smoke-free policies, package warnings, and advertising bans) to all LMICs would cost only $600 million, or $0.11 per person, annually. This amount includes the human resources and physical capital needed to plan, develop, implement, monitor, and enforce the policies [109]. Currently, only $0.02 per person is spent annually on tobacco control in LMICs [110]. Several tobacco control interventions have even proven to be cost saving, which means that for every dollar spent on these interventions there was more than one dollar yielded in return in saved health care costs and human productivity [111] and [112].

3.9. Limitations

Data from national surveys were not available for all countries; or when available, the data might not be comparable in some cases because they were collected using different methodologies or in different years, which might not reflect recent changes in smoking prevalence or tobacco control policies. Despite these limitations, the availability of data from several countries in each region would be sufficient to illustrate the smoking prevalence, trends, and tobacco control policies in all regions.

4. Conclusions

Smoking prevalence is decreasing globally because of heightened awareness about the health hazards of smoking and the implementation of effective tobacco control policies. However, smoking is still a common habit, particularly in Asia, Eastern Europe, Southern Europe, and a number of other LMICs. Additionally, rapid population growth and the expected increase in smoking prevalence because of the adoption of Western lifestyles associated with economic development and urbanization could lead to many more smokers and tobacco-related diseases in parts of Africa and Latin America. Governments, in collaboration with the broader society, must implement effective tobacco control policies where they are lacking. Particular attention should be given to preventing an increase in smoking prevalence among women in LMICs. Although new nicotine delivery systems, such as e-cigarettes, may have the potential to help reduce tobacco-related harm by helping smokers to quit, measures need to be in place to make sure that these systems do not lead to the maintenance of, or a new surge in, tobacco use.

Support and advice about quitting smoking should be a part of all health care practices, including urologic practices, because not only does smoking cause diseases but it also can worsen the prognoses of other diseases by increasing comorbidities, including respiratory and cardiovascular problems.


Author contributions: Farhad Islami had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Islami, Stoklosa, Drope, Jemal.

Acquisition of data: Islami, Stoklosa.

Analysis and interpretation of data: Islami, Stoklosa, Drope, Jemal.

Drafting of the manuscript: Islami, Stoklosa.

Critical revision of the manuscript for important intellectual content: Islami, Stoklosa, Drope, Jemal.

Statistical analysis: None.

Obtaining funding: None.

Administrative, technical, or material support: None.

Supervision: Islami.

Other (specify): None.

Financial disclosures: Farhad Islami certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None.

Funding/Support and role of the sponsor: None.

Appendix A. Supplementary data

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Footnotes

a Surveillance and Health Services Research, American Cancer Society, Atlanta, GA, USA

b Economic and Health Policy Research, American Cancer Society, Atlanta, GA, USA

Corresponding author. Surveillance and Health Services Research, American Cancer Society, Inc., 250 Williams Street, Atlanta, GA 30303, USA. Tel. +1 404 982 3654; Fax: +1 404 321 4669.

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