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For the first time, global smoking prevalence has fallen, but with 1.3 billion global tobacco users, it remains a leading driver of premature death and disease and is a continuing development concern.
Industry commitment to pushing cigarettes drives catastrophic harms: nearly 5 trillion cigarettes are consumed each year, contributing to more than 8 million deaths and nearly US $2 trillion in economic damage.
Progress is tenuous and must be accelerated: The Atlas found smoking among young teens ages 13-15 increasing in 63 countries. In general, slower progress among many larger, poorer countries threaten to outweigh gains in many higher-income countries.
With 1.1 billion smokers in the world and 200 million more who use other tobacco products, tobacco use remains a global epidemic. Global progress is threatened by growing smoking rates among children age 13 to 15 years in many countries and by tobacco industry tactics such as targeting poorer countries with weak regulatory environments and pushing novel products in previously untapped markets.
The Seventh Edition of the Tobacco Atlas, released today by Vital Strategies and the Tobacconomics team at the University of Illinois at Chicago (UIC), finds that, although more people overall are being protected by effective regulatory interventions including tobacco taxes, smoke-free public areas, access restrictions and education, these efforts must be much more robust to contend with an industry whose gross profits climbed to at least US $60 billion in 2020.
Meanwhile, the tobacco industry took full advantage of the COVID-19 pandemic: While countries diverted their attention to the crisis, the tobacco industry took the opportunity to increase market shares, attract new customers, retain smokers and polish their corporate reputations.
“Now in its 20th year, the Tobacco Atlas is a warning call to all those who care about global health and economic development,” said Jeffrey Drope, Ph.D., Research Professor of Public Health at the University of Illinois at Chicago. “It demonstrates unequivocally that tobacco control works: For the first time on record, global smoking rates dropped, to 19.6% in 2019 from 22.6% in 2007. But uneven and anemic implementation of tobacco control measures means that richer countries are unlocking the economic and health benefits of strong tobacco control, while the industry is still preying on emerging economies in ways that will lock in harms for a generation or more. The tobacco industry is a relic whose business for growth still depends on hooking kids on one of the most addictive and harmful consumer products ever invented. An urgent and sustained effort is needed to aggressively regulate this harmful industry and its products to accelerate the end of cigarettes as a mass consumer product, save hundreds of millions of lives, and spur economic growth.”
The atlas identifies devastating health and economic costs of global tobacco use: In 2019 alone, tobacco use caused more than 8.67 million deaths worldwide (6.53 million men, 2.14 million women) and approximately US $2 trillion in economic damage. Most deaths were attributable to smoking, but 1.3 million died from secondhand smoke exposure. In 2019, nearly half of all tobacco-related deaths occurred in countries with high Human Development Index scores. However, deaths from tobacco-related diseases are expected to increase in future years in lower-HDI countries as today’s smokers sicken and die.
Youth tobacco use (girls and/or boys) has increased in 63 of 135 countries surveyed, and now more than 50 million 13- to 15-year-olds smoke cigarettes or use smokeless tobacco products. Currently, countries with the highest prevalence of tobacco use among youth generally have a lower human development index scores. In several of these countries, including Haiti and Mauritania, tobacco use among adolescent girls is now more common than among adult women, indicating that the historically lower tobacco use among females worldwide may not continue in the near future.
“In the wake of COVID-19, countries are reprioritizing public health and investing in strategies to support health and economic growth,” said Nandita Murukutla, Ph.D., Vice President of Research at Vital Strategies. “For countries that want to recover, tobacco control should be high on their agendas. In particular, tobacco taxes are a triple win for health. driving down smoking rates, deterring initiation among youth, and generating revenue that can pay for other health interventions. Graphic pack warnings and plain packaging are proven high-impact, low-cost interventions. Plus, media campaigns can reshape social norms and drive millions to quit at extremely low cost; almost every country in the world is underinvested in media.”
“Global leaders must accelerate tobacco control efforts to protect the health of our youngest generation,” said Dr. Kelly Henning, who leads the Public Health program at Bloomberg Philanthropies. “Tobacco use is a major risk factor for the world’s leading killers including cancer, heart disease, lung disease and diabetes. The faster countries can regulate tobacco and prevent youth from starting, the more lives that can be saved.”
First published in 2002, The Tobacco Atlas uses bold graphics and data visualization to describe the scale of the tobacco epidemic and bring the latest peer-reviewed data to life. The report tracks where progress has been made in tobacco control and details the latest products and tactics being deployed by the tobacco industry to grow its profits and delay or derail tobacco control efforts. The Seventh Edition includes new chapters on: COVID-19; counter-marketing; and race, ethnicity and equity, the last co-authored with the African American Leadership Council on Tobacco Control.
Racialized Targeting of Black Americans by the Tobacco Industry
For decades, the tobacco industry has deliberately targeted Black people in the United States with menthol cigarettes, using aggressive marketing efforts. Currently, more than 85% of Black smokers aged 12 or older use menthol cigarettes compared to 29% for white people in the United States. As a result, tobacco use has become a major vector for death and disease in Black communities in the U.S., taking 45,000 lives a year. Although Black people smoke at similar rates to white people, they have higher associated death rates, including from cancer.
A recent simulation study asserts that a ban on menthol products from 2021 to 2060 could reduce cumulative deaths attributed to smoking and vaping “by 5% (650,000 in total) and reduce life-years lost by 8.8% (11.3 million).” The proposed plan by the U.S. Food and Drug Administration to ban the sale of menthol cigarettes is an overdue step forward.
“For decades, the tobacco industry has targeted Black communities with menthol cigarettes, which are easier to start, harder to quit and deadlier than conventional cigarettes. The tobacco companies unashamedly have appropriated #BlackLivesMatter to sell their products, while simultaneously opposing policies that would actually protect Black health and lives,” said Phillip S. Gardiner, DrPH, Co-Chair of the African American Tobacco Control Leadership Council. “The industry’s weaponization of racial identity and reduced protections for marginalized communities around the world are deepening health disparities. In the U.S., the FDA’s plan to ban menthol cigarettes would save millions of Black lives, and needs to be implemented urgently. Other countries should collect data to assess how racist and discriminatory targeting by tobacco industry shapes inequities in health, and move to address it.”
Noncombustible and Novel Products
Over the last decade, e-cigarettes and heated tobacco products have become increasingly popular in many countries—particularly among youth and nonsmokers—with rapid growth across the spectrum of e-cigarette products, which are gaining market share in some countries. Dramatic increases in initiation among young people, strong evidence of aggressive industry marketing of these products to youth and nonsmokers, and use of child-friendly flavors (e.g., fruit, candy, mint)—often in contexts where youth smoking was declining—have generated enormous concern and controversy. In the U.S., use among young people peaked shortly before the COVID-19 pandemic at 27% among high school students (those reporting any e-cigarette use in the previous 30 days). Worldwide, e-cigarette prevalence is highest in Papua New Guinea, Mauritania and Latvia.
New Markets in Africa Serve as Inroad for Tobacco Growth
The lower tobacco-related burden in Africa reflects its historically lower smoking prevalence. However, with an increase in affordability of tobacco products and the tobacco industry’s aggressive marketing in Africa, smoking prevalence has already started to rise or is likely to substantially increase in the future. With its rapidly growing populations and rising life expectancy, an increase in the number of smokers combined with more years lived with tobacco-related diseases is likely to make Africa suffer the most from future smoking-related death and disease.
In spite of the tobacco industry’s efforts to impede progress, government adoption of proven and innovative tobacco control measures has resulted in the lowest adult tobacco use prevalence to date.
Taxes: It is estimated that increasing the price of tobacco by 50% worldwide through higher taxes would save more than 27 million lives and generate US$ 3 trillion in extra tax revenue over the next 50 years.
Since 2010, New Zealand has increased its cigarette excise tax every year by at least 10% plus inflation. The results: the tax policy has reduced smoking in every socioeconomic and demographic group, with particularly large declines in youth smoking.
Counter-Marketing: Countries should undertake proactive efforts to inform consumers about the harms of tobacco use and the long history of unethical behavior by the tobacco industry.
Laws requiring tobacco packaging to include graphic health warnings are a powerful deterrent. In Kenya, graphic packaging labels were found to be more likely to convince smokers to forgo smoking than labels that contained text-only warnings. Compared to old text warnings, in Kenya, graphic warning labels were 30% to 40% more effective in terms of people noticing the messages and/or wanting to quit because of them.
Mass Media Campaigns: Sustained large-scale media campaigns are proven to effectively drive millions to quit smoking, prevent smoking initiation, shift social norms away from tobacco use, and build an environment that is conducive to policy change.
Media campaigns reduce the prevalence of tobacco use whether they are stand-alone interventions or, when integrated with other interventions, such as taxes or graphic pack warning labels, multipliers. They are also cost-effective. A smokeless tobacco control mass media campaign conducted in India, for example, yielded more than 17 million additional quit attempts at a cost of just US$ 0.06 per attempt.
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