DOI: 10.31038/CST.2024943
Abstract
Smoking is the leading cause of preventable death worldwide. Its toxicity affects every organ. It is a risk factor or aggravating cause of many diseases: cancer, chronic obstructive pulmonary disease, cardiovascular disease, diabetes, HIV infection and tuberculosis, and is a major source of environmental pollution. The socio-economic costs of smoking, already exorbitant, are likely to become unsustainable by 2050 for all countries, particularly low- and middle-income countries. Twenty years after the adoption and implementation of the WHO Framework Convention on Tobacco Control (FCTC), this article aims to take stock of the situation regarding tobacco use and tobacco control. All countries and international health agencies must be involved in the fight against the tobacco pandemic. It is more important than ever to strengthen tobacco control policies, particularly by helping people to stop smoking, to curb the pandemic and its devastating consequences.
Keywords
Smoking, Smoking-related diseases, Tobacco control, Smoking cessation, Public-health
Introduction
Currently more than 20% of the world’s population were smokers. Smoking remains a global health issue despite the gradual reduction in its prevalence. It is responsible for more than 8 million deaths a year worldwide [1]. The toxicity of tobacco products affects every organ in the body, and it is a direct cause, adjuvant and aggravating factor in many diseases: cancer, cardiovascular disease, chronic obstructive pulmonary disease (COPD), diabetes, HIV infection, tuberculosis, environmental health risks, all of which affect all countries, particularly low- and middle-income countries [2]. The prevalence and mortality of these diseases are set to rise sharply by 2050, entailing very high socio- economic costs. Twenty years after the adoption and implementation of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), this article takes stock of the impact of this pandemic and the state of tobacco control, highlighting the necessity to intensify efforts to combat smoking.
Smoking: A Preventable Killer
Smoking is a chronic disease causing many illnesses. It is the leading preventable cause of death. Smoking cessation is associated with an improvement in life expectancy and quality of life, the greater the earlier the cessation, but even after the age of 60 it is associated with an increase in life expectancy [3].
Cancer
In 2022, there will be 20 million new cases and 9.7 million deaths from cancer. It is estimated that there will be more than 35 million new cases of cancer in 2050, an increase of 77% compared with 2022, particularly in low- and middle-income countries, where cancer mortality will double [4].
Smoking is associated with an increased risk of most cancers.The harmful effects of smoking are exacerbated by other factors (alcohol abuse, malnutrition, viral infections, air pollution) [3,4]. Smoking is the main cause of lung cancer (12.4% of all new cancer cases and 18.7% of all cancer deaths). The prevalence of this cancer is increasing in all countries and its incidence could rise by 47% between 2020 and 2040 [4].
The risk of cancer decreases with the length of time smokers have quit [3]. In Korea, a retrospective cohort study of 3 million smokers aged 30 years and older showed that the risk of cancer decreased after 10 years of smoking cessation (HR=0.83 ; 95% CI: 0.80-0.86) compared with continued smoking. The reduction in the risk of lung cancer is more pronounced for quitting before the age of 50 (HR=0.43; 95% CI: 0.35-0.53) compared with quitting at the age of 50 or older (HR=0.61 ; 95% CI: 0.56-0.66). Smoking cessation also reduces the risk of perioperative complications from excisional surgery and the risk of recurrence after cure, it increases life expectancy and quality of life in patients treated for cancer [5].
Cardiovascular Disease
Nearly two million deaths per year are attributable to smoking- related cardiovascular diseases, and the socioeconomic costs of these diseases will rise sharply by 2050 [6].
In high-income countries, tobacco-related cardiovascular mortality is tending to decrease among men, but is increasing among women. In France, for example, the incidence of myocardial infarction before the age of 65 increased by 50% in women (16% in men) between 2005 and 2014. For the same level of smoking, women have a 25% higher risk of coronary heart disease than men [7]. Almost 75% of deaths from cardiovascular disease occur in developing countries, where people have less access to primary health care, screening and early treatment of these diseases.
Mortality from coronary heart disease is reduced by 35% after 2 to 4 years of smoking cessation and by 50% after 10 years. Smoking cessation helps prevent coronary heart disease in young people, where smoking is the main cause. Quitting also reduces the risk of death or reintervention after coronary artery bypass graft surgery or angioplasty, stroke, abdominal aortic aneurysm and obliterative arteritis of the lower limbs [3,7].
Chronic Obstructive Pulmonary Disease
COPD is the fourth leading cause of death worldwide (4.7% of annual mortality), affecting 10.3% of the world’s population, and its prevalence is expected to increase by more than 20% by 2050 [6]. The socioeconomic costs of smoking are increasing, particularly in low- and middle-income countries [8].
Tobacco smoke is the main risk factor for COPD, and women are more susceptible than men [9]. Smoking accelerates the decline in lung function, which is a source of disability. It increases the frequency of exacerbations, leading to death and hospitalisation, and the development of cardiovascular, metabolic and cancer-related comorbidities [9].
Stopping smoking is associated with a reduction in patient-reported symptoms of chronic bronchitis within one to two months. It slows the decline in lung function (FEV1) in COPD patients and reduces the risk of respiratory infections, exacerbations, hospitalisations, death and smoking-related co-morbidities [3,9].
Diabetes
In 2021, 10.5% of adults aged 19-75 worldwide had diabetes mellitus; 90% of them lived in an emerging country. Diabetes will cause 6.7 million deaths. By 2045, 12.2% of adults will have diabetes, and the explosion in the number of cases, in which smoking is a key factor, will place a socioeconomic burden on all countries [10]. The prevalence of smoking is 20.8% in patients with type 2 diabetes and 10-30% in those with type 1 diabetes [11].
Smoking increases insulin resistance, the risk of prediabetes and diabetes in the general population, and gestational diabetes. Diabetic smokers have a 48% excess risk of premature death from all causes and a 36% excess risk of cardiovascular mortality. Smoking increases the risk of macroangiopathy and microangiopathy, hospitalisation for infections, cancer and depression [10,11].
In people with diabetes, smoking cessation reduces the risk of premature mortality, cardiovascular disease and progression of microangiopathy lesions. It also reduces the risk of cancer, hospitalisation for infections and maternal-foetal complications in gestational diabetes. Finally, it facilitates glycaemic control and reduces symptoms of anxiety and depression [11].
HIV Infection
Worldwide, 39 million people are living with HIV ; 630,000 die and 1.3 million are newly infected each year [12]. Antiretroviral therapy (ART) has significantly reduced AIDS-related mortality, but the proportion of deaths from non-AIDS-related causes has increased, mainly due to smoking, which is twice as common as in the general population [13].
HIV-infected smokers have lower CD4 cell counts, higher HIV viral loads and lower self-reported quality of life than HIV-positive non-smokers. Their risk of dying from cardiovascular disease, cancer or bacterial pneumonia is twice as high and with equivalent ART, smokers have a life expectancy 12 years less than non-smokers. [14].
Smoking cessation among people living with HIV is associated with a reduction in all-cause and smoking-related mortality compared with compared with continuous smokers. Stopping smoking reduces the risk of cardiovascular disease, bacterial pneumonia, COPD and cancer, especially lung cancer [13]. WHO recommends that smoking cessation interventions be integrated into HIV care [12].
Tuberculosis
In 2023, tuberculosis (TB) was no longer among the top ten causes of death worldwide, but it still caused 1.3 million deaths. Nearly 8 million new cases of TB were diagnosed: 410,000 people developed a multidrug resistant or resistant to rifampicin TB [15].
More than 80% of TB case and 90% of TB deaths occur in developing countries. The main drivers of the TB epidemic are the spread of HIV and drug-resistant TB, but smoking is responsible for 17.6% of TB case and 15.2% of deaths in high-burden countries [16]. Smoking, whether active or passive, triples the risk of tuberculosis infection and disease, particularly severe and infectious lung disease, forms resistant to anti-tuberculosis drugs, mortality and disease recurrence, and treatment failure [16].
Smoking cessation among smokers with TB is associated with better treatment adherence, higher cure rates, lower mortality and fewer relapses [16]. WHO recommends that TB and tobacco control should be tackled simultaneously to end the TB epidemic, which is one of the United Nations Sustainable Development Goals [17].
Environmental Health Risks
The WHO estimates that 12.6 million deaths worldwide (23% of all deaths) are attributable to the environment; 75% of pollution-related deaths occur in developing countries. Every year, tobacco production, processing and transport emit 84 million tonnes of CO2, contributing to global warming [18].
Air pollution and passive smoking are responsible for 35% of all cases of bronchopulmonary disease worldwide [18] Cigarette smoking produces toxic substances in mainstream smoke (inhaled by the smoker), second-hand smoke (burning of the glowing end of the cigarette), third-hand smoke (deposition of tobacco residue on surfaces) and cigarette butts [19].
The toxic gases and particles produced (polycyclic aromatic hydrocarbons (PAHs), nitrosamines, aldehydes, ketones, alcohols, phenols, PM2.5 and PM10 microparticles) cause lung cancer, COPD, respiratory infections and allergies, as well as cardiovascular, metabolic (type 2 diabetes, thyroid dysfunction), intestinal and mental diseases [20]. These facts are a justification for tobacco control and smoking cessation.
Tobacco Control and Smoking Cessation
Financial Implications of Smoking
A report from the World Health Organization (WHO) estimates that the annual economic cost of smoking worldwide, including health expenditure, lost productivity, is approximately $1.4 trillion (1.8% of the annual global gross domestic product) and in the USA, the economic cost of smoking is nearly $300 billion a year. [20]. Of this amount, 40% affects developing countries. In France, despite a decline in smoking prevalence, the social cost of smoking is estimated at €156 billion annually, representing an annual cost of €2,300 per inhabitant, regardless of smoking status [21]. In Belgium, this cost reaches €20 billion per year and €2,000 per inhabitant per year [22].
Globally, at least 70% of tobacco consumption occurs in low- and middle-income countries. In addition to the morbidity and mortality associated with tobacco use, the cultivation, processing, and disposal of tobacco products pose environmental risks, including atmospheric pollution, global warming, and changes to ecosystems. These challenges impede the economic development of these countries.
Modalities of Tobacco Control
All forms of tobacco use are detrimental to health and well- being. Only a comprehensive, global approach to tobacco control, encompassing regulation of production, marketing and smoking cessation, can effectively safeguard individuals and the environment from the adverse effects of tobacco use.
The WHO Framework Convention on Tobacco Control (FCTC) – A Legal Framework for Tobacco Control
Adopted in 2003 and implemented in 2005, it has been ratified by 183 countries, representing 90% of the world’s population [21]. Its objectives are “to protect present and future generations from the health, social, environmental and economic consequences of tobacco use and exposure to tobacco smoke by providing a framework for the implementation of tobacco control measures by Parties at the national, regional and international levels, with a view to achieving sustained and substantial reductions in the prevalence of tobacco use and exposure to tobacco smoke”.
It has led to the implementation of tobacco control measures: (1) demand reduction (increasing tobacco price and restricting its availability, banning all forms of tobacco advertising, informing and warning the public, providing cessation services); (2) supply reduction (combating illicit trade, banning sales to minors, unit sales, vending machines); (3) evaluation, scientific and technical cooperation on tobacco control.
These measures have already led to a reduction in the prevalence of smoking worldwide, but the devastating effects will only be felt in the long term.
Strengthening Tobacco Control
Tobacco control needs to be continuously strengthened to meet new challenges [1]. For example, banning the sale of all new tobacco products (nicotine pearls and pouchs, disposable vaping products and non-tobacco flavors, the use of menthol) and restricting the places where tobacco is consumed (health units, urban and outdoor areas) will make it possible to reduce the trade and consumption of tobacco. Plain packaging must become the rule, the sale of tobacco products must be strictly regulated and fighting illicit trafficking must be stepped up. Finally, the policy of increasing tobacco prices must be pursued relentlessly. Taken together, these measures will denormalize the image of smokers and smoking [18,21].
The Protection of Young People is a Priority
Smoking often starts in adolescence, and young people are a prime target for the tobacco industry. Their brains are more vulnerable to the effects of psychoactive substances such as nicotine. The prevalence of smoking peaks between the ages of 25 and 35, and tobacco addiction makes it difficult to quit [1].
The promotion of a tobacco-free lifestyle from an early age is based on: (1) the strict application of tobacco control measures (regular and consistent increases in tobacco prices, bans on the sale of tobacco to minors and on new tobacco products: nicotine pearls and pouchs, disposable vaping devices, smoke-free schools, universities and transport); (2) parental information and smoke-free homes; (3) educational initiatives in schools aimed at strengthening young people’s psychosocial skills and critical thinking are effective [24]. All these measures contribute denormalizing tobacco use, preventing smoking and, more generally, addictive behaviour [24,25].
Various actors are involved in preventing smoking (tobacco, cancer, respiratory associations, etc.). In 2024, the theme of World No Tobacco Day was ‘Protecting children from tobacco industry interference’, which raised awareness of the tobacco industry’s harmful influence on young people [26]. Many countries are working towards a ‘tobacco-free adult generation’ in the next decade [22].
Helping People to Stop Smoking
Strategies to Help People Quit
The provision of smoking cessation services is explicitly included in the FCTC (Art. 14) [23]. Smoking cessation is the only way to reduce the morbidity and mortality associated with tobacco use.
Smoking cessation is part of the treatment of diseases related to tobacco use. Health professionals must be involved in this intervention, using evidence-based non-medication strategies (counselling to quit, cognitive behavioral therapy) [26] and medication strategies (nicotine replacement therapy, bupropion, varenicline) [28].
Medications to help people stop smoking are not widely available in low- and middle-income countries because of their high cost and the lack of trained prescribers. Only a public health framework that takes into account the specific characteristics of these countries and based on the denormalization of smoking, the training of health professionals in smoking cessation and the provision of smoking cessation medications by international health authorities, will enable them to implement effective tobacco control [29].
Strategies for Harm Reduction?
There is no threshold of consumption below which smoking is safe [30]. However, can strategies be proposed to reduce risks and harms associated with smoking?
Tobacco companies offer products that deliver nicotine without burning tobacco (heated tobacco, snus, nicotine pearls and pouchs), promising an alternative to traditional cigarettes. These products may reduce the harmful effects associated with smoke inhalation (lung cancer, COPD), but they maintain nicotine dependence, they are not free of toxicity and therefore not credible proposals [31].
The electronic cigarette (e-cig.) vaporizes a nicotine-containing liquid that is much less toxic than tobacco smoke, making it a potential tool for reducing the risks of smoking when used exclusively, although there are uncertainties about the safety of long-term use. Recent studies [28,32] show that e-cig. can help people to quit smoking; further studies are needed to determine whether this benefit applies to smokers in developing countries [33]. The increasing use of e-cigarettes by young people, especially disposable (puff) and high-nicotine devices (JUUL), could lead to nicotine addiction and subsequent cigarette smoking [34], which has led many countries [35] and the WHO to propose measures to prevent e-cig. use by young people [36].
Conclusion
Twenty years after the implementation of the FCTC, every country in the world is affected by the tobacco pandemic, the leading cause of preventable death. Tobacco control in all its forms remains a major public health challenge because of its health, socioeconomic and environmental consequences. More than ever, health professionals need to be involved in smoking prevention initiatives and in helping people to quit.
Contribution to the Article
All authors contributed to the writing and correction of this article.
Conflict of Interest
The authors declare that they have no conflict of interest.
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