The Tobacco Epidemic

Tobacco has a fascinating history. Tobacco is native only to the
Americas and its scientific names include Nicotiana rustica and
Nicotiana tabacum . 1 Tobacco was first experienced by Europeans
when Columbus discovered the Americas in 1492 when they saw
natives smoking “a kind of plant” while exploring what is now
Cuba. The first two Europeans to see this smoking, Rodrigo de
Jerez and interpreter Luis de Torres, even tried it themselves,
becoming the first Europeans to experience tobacco. 1 Tobacco
was brought back to the European countries where it rapidly
spread in usage. Reportedly within 3 months after Columbus
returned to Spain, the two Europeans to first experience tobacco
were perpetual users of the plant. Quite quickly, the addictive
nature of tobacco was noted by the Spanish, which was a novel
experience for Europeans—this habitual use was felt to be un-
Christian, and therefore declared a “sin.” 1
However, there was no turning back. Tobacco rapidly
became a cash crop, with the product flowing from the New
World to support the growing number of users in the Old
World. Jamestown, much to the dismay of King James, was
able to become solvent as a result of tobacco production from
1610 to 1620. 2 When King James could no longer prevent
Jamestown from shipping tobacco, he placed the first New
World tax—on tobacco! 2 In many places in the new colonies,
tobacco was used as a form of currency. 2 Tobacco cultivation
spread throughout many of the colonies, and with the patent
of the new Bonsack machine in 1881, which more efficiently
mechanized production, the manufacturing of cigarettes
began. 2 With the increasing widespread marketing of cigarettes,
the death toll also began to increase.
Globally, in high-income countries, tobacco is the major
causative agent for three of the top five causes of death for
2005: heart disease, stroke, lung cancer, lower respiratory infections,
and chronic obstructive pulmonary disease (COPD). 3 It
is predicted that by 2030, 8.3 million people globally will die
from tobacco-induced disease, and tobacco will be responsible
for 10% of all deaths globally. 4 Smokers will lose on average
10 years of life and 50% of people who smoke will die of a
tobacco-related disease. 5 At present, globally there are a total
of 848,132 lung cancer deaths in men (age-standardized rate
[ASR]: 31.2) and 330,786 deaths in women (ASR: 10.3). 6
Overall, lung cancer is the number one cause of cancer deaths,
accounting for 17.6% of the total number of deaths. Lung
cancer is the leading cause of cancer death in men worldwide;
however, the picture is a little more complicated with either
breast or lung cancer being the number one cause of cancer
deaths in women. The relationship of breast to lung cancer
deaths often reflects the prevalence of smoking among women.
Figure 2.1 illustrates the age-standardized incidence of lung
cancer for regions around the world, which reflects the regions’
historical use of tobacco. 6
The tobacco epidemic is rapidly changing around the
world, and it varies from country to country, mostly according
to the state of economic development. Figure 2.2 illustrates
the Lopez curve of the tobacco epidemic. 7 This model was
developed from the 100-plus year history of smoking, particularly
in the developed world. As demonstrated in Figure 2.2,
a few decades after the peak in smoking prevalence, a country
experiences a peak in lung cancer deaths. This model is even
more powerful when gender is considered. When comparing
gender-related prevalence and rate of deaths, the tobacco
epidemic may then be divided into four stages. Stage I is one
of quite low male and female prevalence of smoking and few
smoking-related deaths. Many low-income countries, such as
in sub-Saharan Africa, are in this stage. Stage II consists of a
rapid rise in the number of male smokers to its peak, a start
in the rise in female smokers, an upswing in the number of
male deaths, but still few deaths in women. In stage III, the
prevalence of male smoking begins to decline, female smoking
is still increasing, and the rate of smoking-attributed male
deaths is at its peak (around 30% of all deaths) with the rates
for women beginning to sharply increase. In stage IV, female
smoking peaks and then declines as male smoking continues
to decline and smoking-attributable death for men and women
decreases. Countries such as the United States and United
Kingdom would be characteristic of stage IV, where the rates
of female smoking–attributable deaths are just reaching their
peaks, while the males rates have already started their decline.
In the United States, cigarettes are by far the predominant
form of tobacco consumption, as seen in Figure 2.3. 8 This pattern
is seen around the world as the tobacco industry increasingly
focuses outside of the more developed economies and
into the more developing economies. The leading tobacco leaf
importers are the Russian Federation, United States, Germany,
Netherlands, Japan, United Kingdom, France, Belgium,
Ukraine, and China. However, the top tobacco leaf exporters
are very different: Brazil, China, United States, Zimbabwe,
Italy, India, Turkey, Malawi, Greece, Argentina. 9 (China,
Brazil, India, and the United States produce over two thirds of
the 2004 global tobacco crop. India uses a significant proportion
of their tobacco for smokeless use.) 9 Thus, the developing
countries are more likely to grow and export the tobacco to
the richer countries who then manufacture the finished cigarettes.
In fact, Altria (the new name for Philip Morris) is the
largest transnational tobacco manufacturer, and it is located
in the United States. Philip Morris also has the number one
global brand of cigarettes: Marlboro, and they sell them in
160 countries of the world. 9 The second largest company is
British American Tobacco, located in the United Kingdom,
and they have one seventh of the global market. Number three
is Japan Tobacco and number four is Imperial Tobacco located
in United Kingdom, and these four companies comprise 43%
of the market. The largest tobacco manufacturer is the China
National Tobacco Corporation, which controls 34% of the
market—most of which is still within China. This, of course,
speaks to the size of the Chinese population and the approximately
60% of men who smoke. 9
Global cigarette consumption has grown dramatically over
the past few decades. The global cigarette consumption has
gone from 10 billion sticks to 2150 billion sticks in 1960, to
5604 billion sticks in 2002, with an estimated 9 trillion cigarettes
in 2025. The top five consumers of cigarettes are China,
United States, Russian Federation, Japan and Indonesia. 9
It is no wonder that the trends for tobacco-related deaths
have steadily climbed as cigarette consumption increases. For
example, the smoking-related mortality in men in the United
Kingdom went from 27% in 1955 to 34% in 1985 and dropped
to 27% in 1995, whereas in former socialist countries, the smoking-
related mortality in men went from 1.3% in 1955 to 3.7%
in 1985 to 5.2% in 1995. 10 This may seem like a low number
in former socialist countries; however, in 2001, the smoking
prevalence in Belarusian men was 56%, Georgian men 53%,
Kazakhstan men 65%, and Russian men 60%. 11 The smoking
prevalence rates in women, as of 2001, were relatively low
( 10%); however, the tobacco industry is undoubtably targeting
this potentially growing market. Evidence has already
demonstrated the significant increases in cigarette production
in parallel with increased consumption in the countries of the
former Soviet Union who have had outside investments from
the transnational tobacco industries. 12 There is enough experience
to predict the tremendous death toll that these smoking
prevalences will have in future years. In China, two thirds of
men start smoking before the age of 25, and with projections,
100 million of the current 300 million Chinese men younger
than the age of 30 will be killed by tobacco. 10
Figure 2.4 demonstrates the comparison of cigarette consumption
between the United States and Japan from 1990 to
the present. 5 With these curves in mind, Figures 2.5 and 2.6 5
demonstrate the trends in lung cancer mortality in six different
countries, including the United States and Japan—all are
considered industrialized, “western” economies. It is striking
to observe the differences between even these “westernized”
economies and between the sexes. It is clear that the United
Kingdom, followed by the United States had the earliest and
most dramatic decline in male lung cancer death rates, whereas
the picture for the women—as predicted by the Lopez curves,
lags significantly behind.
It is also very important to consider the state of tobacco
control within each country and how this impacts the smoking
prevalence rates. Western countries have been at the forefront of
tobacco control, with the resultant decrease in the number of people
starting smoking, but also importantly, the number of people
quitting smoking. Figures 2.7 and 2.8 demonstrate the age-specific
prevalence of current and former smokers by birth cohort in U.S.
men and Japanese men. 5 It is striking to observe the differences
in age of onset of smoking and the numbers of former smokers
(those who have quit).
It is already well established that smoking causes lung cancer—
at least for the past 50 or more years. 13,14 What is interesting
is how the lung cancer epidemic is changing around the world,
depending on the changes in the prevalence of cigarette smoking in
the specific country. As approximately 10% to 20% of smokers will
develop lung cancer—to radically decrease the number of lung cancer
deaths, the prevalence of smoking must significantly decrease.
Lung cancers attributable to smoking vary around the
world—particularly in women. In more developed countries,
smoking causes 90% to 95% of lung cancers in men. For women,
the highest rate of smoking-attributable lung cancer occurs in
North America (85%), northern Europe (74%), and Australia/
New Zealand (72%). In these regions, women have the longest
duration of smoking. For other regions, the attributable fraction
is lower and more highly related to exposure to indoor cooking
fuels. 6 As the rate of smoking increases in women, the attributable
rate necessarily will similarly increase.
The determinants of the risk of smoking to the development
of lung cancer depends on the duration of smoking,
the number of cigarettes smoked per day, the age of smoking
initiation, the type of cigarette smoked, the depth of inhalation,
underlying susceptibility, and family history. Additional
risks include exposure to environmental factors (especially
radon), secondhand smoke, or occupational risks. What has
been changing over time is the increasing exposure to both
mainstream and secondhand smoke, particularly in developing
economies and women, whereas the other causes have remained
fairly stable.
In the United States, the relative risk for developing lung cancer
has been determined in two large, sequential cohort studies
from the American Cancer Society. These relative risks increased
between these studies, from 11.9 to 23.2 in men and 2.7 to 12.8
for women, and this reflected the changes in smoking prevalence. 15
A review of the global literature from over 130 studies showed
similar relative risks for lung cancer from tobacco ranging from 15
to 30. 16 Figure 2.3 from the U.S. Surgeon General Report, 1997,
demonstrates the changes in U.S. tobacco consumption 8 and
Figure 2.9 17 shows the changes in male and female lung cancer
rates, and for comparison, the breast cancer rates in women over
the same time period. From these American data, it was calculated
that the cumulative probability of dying from lung cancer is
14.6% for men and 8.3% for women from smoking, versus only
1.1% in men and 0.9% in women lifelong never-smokers. 18
How can we now relate this information to the rest of
the world? We can examine some of the countries around the
world to see how the lung cancer mortality rates have changed
over time. 19,20 Unfortunately, most countries do not have welld
ocumented smoking histories for the past several decades, but
their historical prevalence can be approximated from the current
lung cancer death rates. Figure 2.10 demonstrates the changes
over the years in the lung cancer death rates in a few representative
countries from Europe. The rates from men can be contrasted
with the rates for women. The similarities between how these data
relate to the Lopez curves are striking. It simply de monstrates
that we can readily predict the death toll from lung cancer if we
do not decrease the smoking rates—particularly among women.
Figure 2.11 illustrates some of the smoking prevalence rates
around the world—where we need to be concerned about the
lung cancer epidemic that is occurring in these countries.