Forget health ministers, legislators, and university trustees. Any hope for ending the tobacco pandemic lies in the commitment of every health professional to make smoking prevention, smoking cessation and relapse prevention top priorities, write Alan Blum and Ransome Eke in The Lancet ahead of World No Tobacco Day 2021.
The commentary from Blum and Eke from the University of Alabama in the United States responds to the results of a research initiative also just published in The Lancet, by the tobacco researchers group called the GBD 2019 Tobacco Collaborators, comprising hundreds of researchers across the world.
The Collaborators 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. See the study details below.
World No Tobacco Day 2021 was held on 31 May and was accompanied by a flurry of research and media articles. These included, in South Africa, a News24 article describing smoking cessation tools and programmes, from the World Health Organization, CANSA and others. The Times reported on a new online tobacco control dashboard which is the first in Africa, the SA Tobacco Control Data Initiative. See both articles below.
Comment
The Lancet – Tobacco control: all research, no action
Alan Blum and Ransome Eke
Published in The Lancet on 27 May 2021.
In a sobering Article in The Lancet, the GBD 2019 Tobacco Collaborators refine methods to estimate the increasing toll of tobacco-attributable morbidity and mortality.
The authors analysed data on prevalence of smoking tobacco use from 204 countries and territories between 1990 and 2019, based on information from 3,625 self-reported nationally representative surveys.
Their analysis, the second to focus on tobacco in the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD), improves on calculations of prevalence of smoking in adults and tobacco-related disease by adding over 800 data sources for prevalence and directly estimating the impact of smoking from Bayesian meta-regression analyses of 36 health outcomes.
The authors found that global age-standardised prevalence of smoking tobacco use decreased by 27·5% (95% uncertainty interval 26·5–28·5) in males and 37·7% (35·4–39·9) in females aged 15 years and older between 1990 and 2019.
However, inexorable population growth has increased the number of smokers from 0·99 billion (0·98–1·00) in 1990 to 1·14 billion (1·13–1·16) in 2019, who consumed 7·41 trillion (7·11–7·74) cigarette-equivalents of tobacco in 2019.
The authors estimated that 5·96 million (77·5%) of 7·69 million smoking-attributable deaths in 2019 occurred in low-income and middle-income countries and that 66 (93%) of 71 countries that had significant increases in such deaths were low-income and middle-income countries.
A wide variation in prevalence of smoking tobacco use was found in these countries that obscures an understanding of the individual-level factors. For instance, WHO reported that although global tobacco cultivation decreased by 15·7% between 2012 and 2018, it increased by 3·4% in Africa.
The number of adult users of tobacco in Africa increased from 64 million in 2000 to 73 million in 2018, but population growth alone might not fully explain this increase. Affordability of cigarettes and economic reliance on tobacco farming to alleviate poverty could account for increasing consumption.
The article by the GBD 2019 Tobacco Collaborators comprises descriptive statistics and is not analytical epidemiological research reporting causal inferences. For more than 70 years, countless epidemiological studies have informed us of the tragic toll of cigarette smoking.
These latest findings remind us of the ongoing worldwide health crisis resulting from tobacco use. But in their minimal conclusion, the authors do not ask what, precisely, we must do with their data.
A perpetual dilemma
How to tackle the global smoking pandemic has become a perpetual dilemma. Tobacco control – a term adopted by 1990s academia to keep radical grassroots anti-smoking activism at arm's length – remains mired in descriptive research that generates data to support policies aimed at reducing smoking.
However, unlike, for instance, mosquito control, the vector – the tobacco industry – survives and thrives. And, like a mutating virus, it adapts to legislative and regulatory attempts to hinder the sale, promotion, and use of its products.
Taxation or sin taxes are not necessarily the most effective tobacco control policy, but to say so risks derision. Cigarette taxes could be set high enough to crush the tobacco industry, but no governments will go that far. They rely on this revenue for deficit reduction and for things other than curbing smoking.
The vaunted 1998 Master Settlement Agreement between the United States state attorneys general and the tobacco industry, ostensibly to recover medical costs for disease caused by smoking, epitomises government addiction to tobacco money.
States have spent only 3% of the annual payments to them from the industry to fight smoking, which in some instances is less than before the Master Settlement Agreement. Increases in tobacco taxation might have reduced sales to the poorest consumers, but US cigarette manufacturers are still making huge profits and tobacco stocks remain a healthy investment.
The tobacco industry's never-ending plea that more research is needed before restricting or banning its products has been heeded for too long. In 1985, US Surgeon General C Everett Koop pointed to the overwhelming scientific base – already more than 50 000 studies – linking smoking to various chronic diseases.
A PubMed search on 20 May 2021, using the terms “smoking”, “cigarettes”, “tobacco”, and “e-cigarettes” yielded 358 858 publications since 1 January 1985. Are all these additional papers, and their funding, still insufficient?
Only in the mid-2000s did we begin to flatten the curve for lung cancer mortality for both men and women in the United Kingdom and the US, long after the Royal College of Physicians and the US Surgeon General Luther Terry told us what we needed to do.
By stark contrast with the trillions of dollars allocated by US Congress to address COVID-19, no major funding has ever been approved to fight smoking and its promotion.
The tobacco industry remains the foremost obstacle to tobacco control. State-owned cigarette manufacturers – notably, the China tobacco monopoly in the world's largest cigarette market – pose a daunting challenge to public health. The US, the UK, Japan, South Korea, Switzerland, and Sweden, among other countries, also host powerful tobacco companies.
Unlike the earnest but static WHO Framework Convention on Tobacco Control, which has not been well implemented, the tobacco industry is dynamic and resilient. The livelihoods of 100 million people are dependent on the production, distribution, and sale of tobacco products.
No jobs in tobacco control will be lost if smoking and the resultant diseases increase. Public health failures engender research funding.
Forget health ministers, legislators, and university trustees. Any hope for ending the tobacco pandemic lies in the commitment of every health professional to make smoking prevention, smoking cessation, and relapse prevention top priorities.
Philanthropic foundations can best support this goal by shifting funds from research to hard-hitting, paid, mass media campaigns that indict tobacco companies, shatter myths (eg, that the filter makes smoking safer), and subvert cigarette sales through brand-name satire.
* We declare no competing interests.
Study details
Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990–2019: a systematic analysis from the Global Burden of Disease Study 2019
GBD 2019 Tobacco Collaborators
Published in The Lancet on 27 May 2021.
Summary
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.
Want to stop smoking? Try these 'quit friendly’ tools and programmes from WHO and CANSA
Smoking cessation programmes, including online ones, are successful in helping people to quit, wrote Zakiyah Ebrahimfor Health24 on 1 June 2021.
The number of smokers has reached an all-time high of 1.1 billion. In 2019, the habit was responsible for the death of nearly eight million people, a study published in The Lancet last week. The results were based on examining smoking trends in 204 countries, including South Africa.
Quitting smoking is a difficult and complex process, and in many countries, the lack of adequate cessation programmes makes it even more challenging. In the context of COVID-19, it is more important than ever as evidence indicates that smokers are more likely to develop severe COVID-19 than non-smokers.
According to the Health 24 story, as part of the global theme of World No Tobacco Day 2021, Commit to Quit, a panel of speakers from the National Department of Health; the World Health Organization (WHO); civil society; and medical and nursing organisations, discussed what is being done to turn the tide on the harm done by tobacco in South Africa.
Dr Sharon Nyatsanza, project and communications manager at the National Council Against Smoking, University of Witwatersrand, discussed two online cessation smoking programmes – one launched by the WHO and the other by CANSA (Cancer Association of South Africa) – currently used by people locally and all over the world.
Currently, evidence-based cessation approaches recommended by WHO include calling a quitline; accessing nicotine replacement therapies; and support in the form of counselling and cessation programmes.
According to Nyatsanza, available data suggests that 21.5% of South Africans use tobacco products – but that 70% want to quit – reports Health24.
“Because nicotine is addictive, many of them struggle to quit,” she said. “So we need to keep strengthening cessation support because it’s been proven to increase the quit successes.”
The EX Plan by BecomeAnEX®, a free digital quit-smoking programme developed by Truth Initiative® in collaboration with Mayo Clinic, for example, has been found to quadruple a smoker’s chance of quitting.
It is also much more effective than the “cold turkey” method, where smokers who attempt to quit do so without support, counselling or medications. A “quit-friendly environment” that gives people the skills to control their behaviour while providing a supportive environment should be the focus, among other tools, said Nyatsanza.
eKick Butt programme
More locally, CANSA has a free-to-use eKick Butt online smoking cessation programme that gives people, through a series of emails, surveys and downloads, guidance and mentorship as they quit smoking, helping to make non-smoking a lifelong habit. The programme supplies users with a series of handy tools that have been tried and tested to help them quit for good.
National quitline
South Africa’s national quitline offers people the chance to quit smoking via a telephone call. Smokers are given information, advice and help in quitting, explained Nyatsanza. In-depth counselling is also provided by a cessation expert whenever it is needed.
The number is 011 720 3145, which is printed on every cigarette package. There is also a 30-day support system available via the WhatsApp line (072 766 4812).
Full report on the Health24 site. See the link below.
New dashboard sets the record straight about smoking in SA
South Africans, researchers and policy-makers wanting information on tobacco-use trends can now access this vital data in real time after the launch on an online tobacco control dashboard which is the first in Africa, writes Sipokazi Fokazi for The Times.
Launched by deputy health minister Joe Phaahla to mark World No Tobacco Day, the SA Tobacco Control Data Initiative aims to help South Africans understand data needs and gaps, and provide reliable information on tobacco control measures and usage.
Phaahla said the initiative is the answer to the continued need for reliable data to inform policy, The Times reports.
It is the brainchild of Development Gateway, an international NGO that provides technical advisory services to governments and organisations, and the University of Cape Town-based Research Unit on the Economics of Excisable Products.
The dashboard shows SA has a high cigarette prevalence with 19% of adults smoking. At least 34% of adult men smoke, compared with about 7% of women. Tobacco use costs the economy R42bn every year — equating to annual salaries for 215,000 teachers.
It also shows more than one million South Africans regularly smoked e-cigarettes in 2018, writes The Times.
“The initiative aims to understand the data needs and gaps specific to SA, identify reliable data, and develop websites that enable policy-makers to use essential data more effectively to inform policy in six African countries, including SA,” said Megan Lille of the Research Unit of Economics of Excisable Products. “It equips decisionmakers with up-to-date evidence to promote tobacco control and public health.”
Full report on the Health24 site. See the link below.
The Lancet commentary – Tobacco control: all research, no action (Open access)
The Times story – New dashboard sets the record straight about smoking in SA (Open access)
SA Tobacco Control Data Initiative
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