Measuring the accumulated hazards of smoking: global and regional estimates for 2000

Health and health-care systems in southeast Asia: diversity and transitions

Southeast Asia is a region of enormous social, economic, and political diversity, both across and within countries, shaped by its history, geography, and position as a major crossroad of trade and the movement of goods and services. These factors have not only contributed to the disparate health status of the region's diverse populations, but also to the diverse nature of its health systems, which are at varying stages of evolution. Rapid but inequitable socioeconomic development, coupled with differing rates of demographic and epidemiological transitions, have accentuated health disparities and posed great public health challenges for national health systems, particularly the control of emerging infectious diseases and the rise of non-communicable diseases within ageing populations. While novel forms of health care are evolving in the region, such as corporatised public health-care systems (government owned, but operating according to corporate principles and with private-sector participation) and financing mechanisms to achieve universal coverage, there are key lessons for health reforms and decentralisation. New challenges have emerged with rising trade in health services, migration of the health workforce, and medical tourism. Juxtaposed between the emerging giant economies of China and India, countries of the region are attempting to forge a common regional identity, despite their diversity, to seek mutually acceptable and effective solutions to key regional health challenges. In this first paper in the Lancet Series on health in southeast Asia, we present an overview of key demographic and epidemiological changes in the region, explore challenges facing health systems, and draw attention to the potential for regional collaboration in health.

Prevalence and correlates of tobacco use among a sample of MSM in Shanghai, China

INTRODUCTION

Men who have sex with men (MSM) have higher smoking rates than the general population in the United States, but less is known about smoking among MSM in developing countries. Thus, we examined the prevalence and correlates of smoking among MSM in China.

METHODS

We conducted a cross-sectional study of 404 MSM in Shanghai, China (half of whom were male sex workers), recruited through respondent-driven sampling. Assessments included sociodemographics; tobacco, alcohol, and drug use; the Center for Epidemiological Studies Depression Scale (CES-D); the Social Provisions Scale (SPS); and the Lesbian, Gay, and Bisexual Identity Scale (LGBIS).

RESULTS

Smoking prevalence was 65.9% in this sample. Recent smoking (i.e., in the past 3 months) was significantly associated with lower education, greater alcohol use, and higher LGBIS scores, after controlling for important sociodemographics. Among smokers, smoking ≥10 cigarettes per day (CPD), in comparison with <10 CPD, was related to older age and lower LGBIS scores and marginally related to heavy alcohol use. Although bivariate analyses indicated a relationship of CES-D and SPS scores to recent smoking, these factors did not contribute to the regression models.

CONCLUSIONS

Smoking rates among MSM in China are higher than MSM in the United States and men in China. Less comfort with one's sexual orientation was related to smoking, particularly light smoking. Heavier alcohol consumption, lower education, and older age were also associated with smoking. Future research should confirm these findings and examine mediators and moderators of these relationships in order to inform cessation interventions and tobacco control policy.

Prevalence of smoking among adults residing in the Federal District of Brasília and in the state capitals of Brazil, 2008

OBJECTIVE

To determine the prevalence of smoking in the adult population of Brazil, in order to propose recommendations for the reduction of tobacco use.

METHODS

This was a population-based, cross-sectional study including a sample composed of residents (> 18 years of age) of the capital cities of 26 Brazilian states and in the Federal District of Brasília, Brazil. For the determination of sample size, a 95% confidence interval and a 2% sample error were defined. The participants were selected and interviewed by means of the Sistema de Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico (VIGITEL, Telephone-based System for the Surveillance of Risk and Protective Factors for Chronic Diseases).The proportion of smokers and the number of cigarettes smoked per day were estimated and stratified according to sociodemographic variables. In addition, the male/female ratio was estimated for the prevalence of smoking.

RESULTS

The prevalence of smoking was 16.1% (20.5% among males and 12.4% among females). The proportion of adults that reported smoking > 20 cigarettes a day was 4.9%, being greater in males (6.5% vs. 3.6%). The prevalence of smoking was greater among individuals with a lower level of education (< 8 years of schooling). The number of cigarettes smoked per day by males was approximately the double that smoked by females.

CONCLUSIONS

The VIGITEL estimates indicate a reduction in the prevalence of smoking, which was, however, still greater among males than among females. The VIGITEL has been fundamental to monitoring smoking, as well as to informing decisions regarding public policies for health promotion and the prevention of chronic nontransmissible diseases.

Smoking in Ghana: a review of tobacco industry activity

Background:

African countries are a major potential market for the tobacco industry, and the smoking epidemic is at various stages of evolution across the continent. Ghana is an African country with a low prevalence of smoking despite an active tobacco industry presence for over 50 years. This study explores potential reasons for this apparent lack of industry success.

Objective:

To explore the history of tobacco industry activity in Ghana and to identify potential reasons for the current low prevalence of smoking.

Methods:

A search was made of tobacco industry archives and other local sources to obtain data relevant to marketing and consumption of tobacco in Ghana.

Findings:

British American Tobacco, and latterly the International Tobacco Company and its successor the Meridian Tobacco Company, have been manufacturing cigarettes in Ghana since 1954. After an initial sales boom in the two decades after independence in 1957, the sustained further increases in consumption typical of the tobacco epidemic in most countries did not occur. Possible key reasons include the taking of tobacco companies into state ownership and a lack of foreign exchange to fund tobacco leaf importation in the 1970s, both of which may have inhibited growth at a key stage of development, and the introduction of an advertising ban in 1982. BAT ceased manufacturing cigarettes in Ghana in 2006.

Conclusion:

The tobacco industry has been active in Ghana for over 50 years but with variable success. The combination of an early advertising ban and periods of unfavourable economic conditions, which may have restricted industry growth, are likely to have contributed to the sustained low levels of tobacco consumption in Ghana to date.

The present and future burden of urinary bladder cancer in the world

Urinary bladder cancer (UBC) is a common disease worldwide. At any point in time 2.7 million people have a history of UBC. The incidence of UBC varies over the world with highest rates in developed communities. But the burden of UBC will increase in less developed areas of the world. These changes can be attributed to global changes in exposure to risk factors for UBC and growth and aging of the world population.

Mortality attributable to smoking in China

BACKGROUND

Smoking is a risk factor for many diseases and has been increasingly prevalent in economically developing regions of the world. We aimed to estimate the number of deaths attributable to smoking in China.

METHODS

We conducted a large, prospective cohort study in a nationally representative sample of 169,871 Chinese adults who were 40 years of age or older. Investigators for the China National Hypertension Survey collected data on smoking and other risk factors at a baseline examination in 1991 using a standard protocol. Follow-up evaluation was conducted in 1999 and 2000, with a response rate of 93.4%. We used multivariable-adjusted relative risk, prevalence of smoking, mortality, and population size in each age group, stratified according to sex, to calculate the number of deaths attributable to smoking in 2005.

RESULTS

There was a significant, dose-response association between pack-years smoked and death from any cause in both men and women after adjustment for multiple risk factors (P<0.001 for trend). We estimated that in 2005, a total of 673,000 deaths (95% confidence interval [CI], 564,700 to 781,400) were attributable to smoking in China: 538,200 (95% CI, 455,800 to 620,600) among men and 134,800 (95% CI, 108,900 to 160,800) among women. The leading causes of smoking-related deaths were as follows: cancer, 268,200 (95% CI, 214,500 to 321,900); cardiovascular disease, 146,200 (95% CI, 79,200 to 213,100); and respiratory disease, 66,800 (95% CI, 20,300 to 113,300).

CONCLUSIONS

Our study documents that smoking is a major risk factor for mortality in China. Continued strengthening of national programs and initiatives for smoking prevention and cessation is needed to reduce smoking-related deaths in China.

Male tobacco smoke load and non-lung cancer mortality associations in Massachusetts

Background

Different methods exist to estimate smoking attributable cancer mortality rates (Peto and Ezzati methods, as examples). However, the smoking attributable estimates using these methods cannot be generalized to all population sub-groups. A simpler method has recently been developed that can be adapted and applied to different population sub-groups. This study assessed cumulative tobacco smoke damage (smoke load)/non-lung cancer mortality associations across time from 1979 to 2003 among all Massachusetts males and ages 30–74 years, using this novel methodology.

Methods

Annual lung cancer death rates were used as smoke load bio-indices, and age-adjusted lung/all other (non-lung) cancer death rates were analyzed with linear regression approach. Non-lung cancer death rates include all cancer deaths excluding lung. Smoking-attributable-fractions (SAFs) for the latest period (year 2003) were estimated as: 1-(estimated unexposed cancer death rate/observed rate).

Results

Male lung and non-lung cancer death rates have declined steadily since 1992. Lung and non-lung cancer death rates were tightly and steeply associated across years. The slopes of the associations analyzed were 1.69 (95% confidence interval (CI) 1.35–2.04, r = 0.90), and 1.36 (CI 1.14–1.58, r = 0.94) without detected autocorrelation (Durbin-Watson statistic = 1.8). The lung/non-lung cancer death rate associations suggest that all-sites cancer death rate SAFs in year 2003 were 73% (Sensitivity Range [SR] 61–82%) for all ages and 74% (SR 61–82%) for ages 30–74 years.

Conclusion

The strong lung/non-lung cancer death rate associations suggest that tobacco smoke load may be responsible for most prematurely fatal cancers at both lung and non-lung sites. The present method estimates are greater than the earlier estimates. Therefore, tobacco control may reduce cancer death rates more than previously noted.

Preventing cancer through tobacco and infection control: how many lives can we save in the next 10 years?

This paper presents projections for cancer mortality, incidence and burden of disease (as disability adjusted life years) for 2005, 2015 and 2030. The projections are based on the latest available WHO mortality estimates from 2002, updated with mortality data from 107 countries and augmented by region and site-specific cancer survival models. Cancer accounted for an estimated 7.6 million deaths in 2005, and 72% of these deaths were in low-income and middle-income countries. For cancer deaths under age 70, 79% are estimated to occur in low-income and middle-income countries. Without intervention, the number of global deaths is projected to rise to 9 million in 2015 and a further 11.5 million in 2030. The rising burden of this disease, especially in low-income and middle-income countries, leads us to propose a global goal for cancer: a 2% reduction per annum over and above that which may happen as a result of current trends in prevention, case management and treatment. Achieving this goal would result in 7.7 million fewer deaths from cancer over the period from 2005 to 2015. More of these deaths will be averted in low-income and middle-income countries than in high-income countries. The scientific knowledge to achieve this goal already exists, and the target could be reached through effective cancer prevention strategies, including tobacco control, hepatitis B vaccination and prevention of cervical cancer.

Is inequality at the heart of it? Cross-country associations of income inequality with cardiovascular diseases and risk factors

Despite a number of cross-national studies that have examined the associations between income inequality and broad health outcomes such as life expectancy and all-cause mortality, investigations of the cross-country relations between income inequality and cardiovascular disease (CVD) morbidity, mortality, and risk factors are sparse. We analyzed the cross-national relations between income inequality and age-standardized mean body mass index (BMI), serum total cholesterol, systolic blood pressure (SBP), obesity prevalence, smoking impact ratio (SIR), and age-standardized and age-specific disability-adjusted life-years (DALYs) and mortality rates from coronary heart disease (CHD) and stroke, controlling for multiple country-level factors and specifying 5- to 10-year lag periods. In multivariable analyses primarily limited to industrialized countries, countries in the middle and highest (vs. lowest) tertiles of income inequality had higher absolute age-standardized obesity prevalences in both sexes. Higher income inequality was also related to higher mean SBP in both sexes, and higher SIR in women. In analyses of larger sets of countries with available data, positive associations were observed between higher income inequality and mean BMI, obesity prevalence, and CHD DALYs and mortality rates. Associations with stroke outcomes were inverse, yet became positive with the inclusion of eastern bloc and other countries in recent economic/political transition. China was also identified to be an influential data point, with the positive associations with stroke mortality rates becoming attenuated with its inclusion. Overall, our findings are compatible with harmful effects of income inequality at the national scale on CVD morbidity, mortality, and selected risk factors, particularly BMI/obesity. Future studies should consider income inequality as an independent contributor to variations in CVD burden globally.

Methodologies used to estimate tobacco-attributable mortality: a review

BACKGROUND

One of the most important measures for ascertaining the impact of tobacco on a population is the estimation of the mortality attributable to its use. To measure this, a number of indirect methods of quantification are available, yet there is no consensus as to which furnishes the best information. This study sought to provide a critical overview of the different methods of attribution of mortality due to tobacco consumption.

METHOD

A search was made in the Medline database until March 2005 in order to obtain papers that addressed the methodology employed for attributing mortality to tobacco use.

RESULTS

Of the total of 7 methods obtained, the most widely used were the prevalence methods, followed by the approach proposed by Peto et al, with the remainder being used in a minority of studies.

CONCLUSION

Different methodologies are used to estimate tobacco attributable mortality, but their methodological foundations are quite similar in all. Mainly, they are based on the calculation of proportional attributable fractions. All methods show limitations of one type or another, sometimes common to all methods and sometimes specific.

The choice among past trends as a basis for the prediction of future trends in old-age mortality

We explored the extent to which projections of future old-age mortality trends differ when different projection bases are used. For seven European countries, four alternative sets of annual rates of mortality change were estimated with age-period log-linear regression models, and subsequently applied to age-specific all-cause mortality rates (80+) in 1999 to predict mortality levels up to 2050. On average, up to 2050, e80 is predicted to increase further by 2.33 years among men and 4.03 years among women. Choosing a historical period of 25 instead of 50 years results in higher predicted gains in e80 for men but lower gains for women. Choosing non-smoking-related mortality instead of all-cause mortality leads to higher gains for women and mixed results for men. In all alternatives there is a strong divergence of predicted mortality levels between the countries. Future projections should be preceded by a thorough study of past trends and their determinants.

Costs and benefits of smoking cessation aids: making a case for public reimbursement of nicotine replacement therapy in Australia

BACKGROUND

Tobacco smoking is the leading preventable cause of morbidity and mortality in Australia and other developed countries. Of the pharmacological aids that are available for smoking cessation, bupropion (Zyban SR) is eligible for public reimbursement on the Australian Pharmaceutical Benefits Scheme (PBS), whereas nicotine replacement therapy (NRT) is not. Information on the cost-effectiveness and financial impact of public reimbursement of these strategies can better inform debate about their inclusion or exclusion in public reimbursement schemes.

OBJECTIVE

To estimate the cost-effectiveness of bupropion and NRT, and the potential financial impact of public reimbursement of NRT in Australia.

DESIGN

A cost-effectiveness analysis using a deterministic Markov model, and cost per disability-adjusted life year (DALY) averted over a lifetime as the outcome measure.

POPULATION

Current smokers, motivated to quit, in Australia in 2000.

INTERVENTIONS

(1) NRT; (2) bupropion; and (3) a combined strategy using bupropion as the first-line treatment and NRT in those who fail to quit smoking or have adverse reactions to bupropion.

RESULTS

Quitting smoking can increase life expectancy of current smokers by 1-7.6 years depending on age at cessation and sex. Providing bupropion to current smokers who are motivated to quit would cost A$7900 (95% uncertainty interval A$6000 to A$10,500) for each DALY averted; NRT patches would cost A$17,000 (A$9000 to A$28,000) for each DALY averted, with similar results even if used as a second-line treatment following initial failure to quit using bupropion. If 6% of current smokers were to use NRT following inclusion on the PBS, this would result in an annual cost of A$40-110 million to the PBS depending on the listed price.

CONCLUSIONS

Compared with other drugs included on the PBS, bupropion and NRT are both highly cost-effective smoking cessation interventions, and including NRT on the PBS would have a moderate financial impact. Given the sizeable health burden of smoking, and the large individual benefits of quitting smoking, increasing the availability of alternative aids and uptake of these strategies through public reimbursement would be a positive and rational step towards further reducing tobacco-related disease burden in Australia and other countries where NRT is currently not subsidised.

Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use

In 2005, WHO set a global goal to reduce rates of death from chronic (non-communicable) disease by an additional 2% every year. To this end, we investigated how many deaths could potentially be averted over 10 years by implementation of selected population-based interventions, and calculated the financial costs of their implementation. We selected two interventions: to reduce salt intake in the population by 15% and to implement four key elements of the WHO Framework Convention on Tobacco Control (FCTC). We used methods from the WHO Comparative Risk Assessment project to estimate shifts in the distribution of risk factors associated with salt intake and tobacco use, and to model the effects on chronic disease mortality for 23 countries that account for 80% of chronic disease burden in the developing world. We showed that, over 10 years (2006-2015), 13.8 million deaths could be averted by implementation of these interventions, at a cost of less than US$0.40 per person per year in low-income and lower middle-income countries, and US$0.50-1.00 per person per year in upper middle-income countries (as of 2005). These two population-based intervention strategies could therefore substantially reduce mortality from chronic diseases, and make a major (and affordable) contribution towards achievement of the global goal to prevent and control chronic diseases.

National Income, Inequality and Global Patterns of Cigarette Use

Declining tobacco use in high-income nations and rising tobacco use in low- and middle-income nations raises questions about the sources of worldwide patterns of smoking. Theories posit a curvilinear influence of national income based on the balance of affordability and health-cost effects. In addition, however, economic inequality, gender inequality and government policies may moderate the rise and fall in smoking prevalence with national income. This study tests these arguments using aggregate data for 145 nations and measures of smoking prevalence circa 2000. The results show nonlinear effects of national income for males that take the form of an inverted U, but show linear effects for females. They also show non-additive effects of economic inequality for males that moderate both the rise and decline of smoking with national income and non-additive effects of gender equality for females that moderate the positive effect of national income.

Trends in the prevalence of smoking in Russia during the transition to a market economy

BACKGROUND

Changes in smoking, particularly an increase in women, were predicted to follow the aggressive campaigns of multinational tobacco companies in transitional Russia. However, such changes have not yet been demonstrated unequivocally.

OBJECTIVE

To examine smoking trends by gender, education and area of residence.

METHODS

Data from 10 rounds of the Russia Longitudinal Monitoring Survey (1992-2003), consisting of more than 3000 men and 4000 women in each round, were used. The mean reported ages of first smoking in current smokers were compared between 10-year birth cohorts.

RESULTS

Between 1992 and 2003, smoking prevalence doubled among women from 6.9% (95% CI 6.3% to 7.6%) to 14.8% (13.9% to 15.7%) and increased among men from 57.4% (95% CI 56.0% to 58.8%) to 62.6% (61.1% to 64.1%). In both sexes, the rise was significantly greater in the least educated, markedly so in women (a doubling vs a 1.5-fold rise in the most educated). Although prevalence of smoking among women was considerably higher in Moscow and St Petersburg than in rural areas, the dramatic threefold increase in prevalence in rural women was significantly greater than in the main cities (36%, p<0.001). The mean age of first smoking was significantly lower in women born after 1960, but in men it was stable between cohorts.

CONCLUSIONS

For the first time, it has been shown unequivocally that smoking among women increased markedly during the transition to a market economy in Russia. The already high prevalence of smoking among men has continued to rise. These changes are likely to reflect the activity of the tobacco industry and provide further evidence of the harms of privatisation. Effective tobacco control policies are urgently needed.

Smoke load/cancer death rate associations in Korea females, 1985-2004

BACKGROUND

Korea female death rates from many cancers have risen rapidly since 1985. The sources of those cancer death epidemics are unclear but may be related to rising cumulative tobacco smoke damage (smoke load). We assessed Korea female smoke load/cancer death rate associations from 1985 to 2004.

METHODS

Lung cancer rates were used as a smoke load bio-index. Subtracting lung, stomach, and uterine corpus cancer death World age standard rates (rates) from all-sites rates gave us non-lung-stomach-uterine corpus (NLSUc) rates. Lung/NLSUc linear regressions were run, adjusted for autocorrelation. Estimated, lower, and upper bound smoking-attributable fractions (SAFs) were calculated using the formula SAF=1-{(unexposeds' cancer death rate)/(observed rate)}, based on the linear regression and respective best, upper, and lower bound estimated lung, stomach, and uterine cancer death rates in the unexposed.

RESULTS

Lung cancer death rates (smoke load) can explain 88% of the variance in NLSUc rates from 1985 to 2004 after adjusting for autocorrelation. The estimated Korea female all-sites cancer death rate SAF in 2004 was 43% (sensitivity range 29-56%).

CONCLUSIONS

Smoke load, probably from tobacco given the epidemic time course, may cause a large cancer death burden in Korea females despite their very low self-reported prevalence of smoking.

The fraction of ischaemic heart disease and stroke attributable to smoking in the WHO Western Pacific and South-East Asian regions

BACKGROUND

Tobacco will soon be the biggest cause of death worldwide, with the greatest burden being borne by low and middle-income countries where 8/10 smokers now live.

OBJECTIVE

This study aimed to quantify the direct burden of smoking for cardiovascular diseases (CVD) by calculating the population attributable fractions (PAF) for fatal ischaemic heart disease (IHD) and stroke (haemorrhagic and ischaemic) for all 38 countries in the World Health Organization Western Pacific and South East Asian regions.

DESIGN AND SUBJECTS

Sex-specific prevalence of smoking was obtained from existing data. Estimates of the hazard ratio (HR) for IHD and stroke with smoking as an independent risk factor were obtained from the approximately 600,000 adult subjects in the Asia Pacific Cohort Studies Collaboration (APCSC). HR estimates and prevalence were then used to calculate sex-specific PAF for IHD and stroke by country.

RESULTS

The prevalence of smoking in the 33 countries, for which relevant data could be obtained, ranged from 28-82% in males and from 1-65% in females. The fraction of IHD attributable to smoking ranged from 13-33% in males and from <1-28% in females. The percentage of haemorrhagic stroke attributable to smoking ranged from 4-12% in males and from <1-9% in females. Corresponding figures for ischaemic stroke were 11-27% in males and <1-22% in females.

CONCLUSIONS

Up to 30% of some cardiovascular fatalities can be attributed to smoking. This is likely an underestimate of the current burden of smoking on CVD, given that the smoking epidemic has developed further since many of the studies were conducted.

A cross-cultural and historical survey of tobacco use among various ethnic groups

This review of tobacco use in diverse historical and cultural contexts reveals a range of behaviors engaged in and perspectives held by members of respective ethnic groups, such as whether to consider tobacco as a medicine or as a problem. After its introduction to Western societies, many attributed tobacco with an array of medicinal uses, while condemning recreational use and identifying it as immoral. Tobacco has been used variously by respective ethnic groups at different times and places and these customs have flavored understandings of the relationships between tobacco and the body. Considerable ethnic variation exists not only in terms of tobacco use and abuse, but also with respect to pharmacogenetic factors that influences the consequences of tobacco exposure. There have also been different societal responses to the use of tobacco, including those related to the media, as well as to issues of treatment and prevention.

Global Patterns and Determinants of Sex Differences in Smoking

The worldwide spread of tobacco use in recent decades raises questions about the relative prevalence of smoking among men and women. Does the degree of gender equality in nations promote equality in cigarette use? Does rising use of cigarettes by women stem from the stage of cigarette diffusion and earlier increases among men? Or have changes in economic factors and smoking policy affected the sexes differently? This study uses aggregate data for 106 nations, measures of smoking prevalence circa 2000, and lagged measures of gender equality, cigarette diffusion, and tobacco access to address these questions and evaluate the underlying theories. With the logged ratio of female to male prevalence as the dependent variable, regression results reveal that gender equality has inconsistent effects on women's smoking relative to men, cigarette diffusion has more consistent and moderately strong effects, and economic factors have weak effects. Global patterns of adoption of cigarettes by women appear most closely associated with the early adoption by men and then movement through a regular pattern of cigarette diffusion.

Projections of global mortality and burden of disease from 2002 to 2030

BACKGROUND

Global and regional projections of mortality and burden of disease by cause for the years 2000, 2010, and 2030 were published by Murray and Lopez in 1996 as part of the Global Burden of Disease project. These projections, which are based on 1990 data, continue to be widely quoted, although they are substantially outdated; in particular, they substantially underestimated the spread of HIV/AIDS. To address the widespread demand for information on likely future trends in global health, and thereby to support international health policy and priority setting, we have prepared new projections of mortality and burden of disease to 2030 starting from World Health Organization estimates of mortality and burden of disease for 2002. This paper describes the methods, assumptions, input data, and results.

METHODS AND FINDINGS

Relatively simple models were used to project future health trends under three scenarios-baseline, optimistic, and pessimistic-based largely on projections of economic and social development, and using the historically observed relationships of these with cause-specific mortality rates. Data inputs have been updated to take account of the greater availability of death registration data and the latest available projections for HIV/AIDS, income, human capital, tobacco smoking, body mass index, and other inputs. In all three scenarios there is a dramatic shift in the distribution of deaths from younger to older ages and from communicable, maternal, perinatal, and nutritional causes to noncommunicable disease causes. The risk of death for children younger than 5 y is projected to fall by nearly 50% in the baseline scenario between 2002 and 2030. The proportion of deaths due to noncommunicable disease is projected to rise from 59% in 2002 to 69% in 2030. Global HIV/AIDS deaths are projected to rise from 2.8 million in 2002 to 6.5 million in 2030 under the baseline scenario, which assumes coverage with antiretroviral drugs reaches 80% by 2012. Under the optimistic scenario, which also assumes increased prevention activity, HIV/AIDS deaths are projected to drop to 3.7 million in 2030. Total tobacco-attributable deaths are projected to rise from 5.4 million in 2005 to 6.4 million in 2015 and 8.3 million in 2030 under our baseline scenario. Tobacco is projected to kill 50% more people in 2015 than HIV/AIDS, and to be responsible for 10% of all deaths globally. The three leading causes of burden of disease in 2030 are projected to include HIV/AIDS, unipolar depressive disorders, and ischaemic heart disease in the baseline and pessimistic scenarios. Road traffic accidents are the fourth leading cause in the baseline scenario, and the third leading cause ahead of ischaemic heart disease in the optimistic scenario. Under the baseline scenario, HIV/AIDS becomes the leading cause of burden of disease in middle- and low-income countries by 2015.

CONCLUSIONS

These projections represent a set of three visions of the future for population health, based on certain explicit assumptions. Despite the wide uncertainty ranges around future projections, they enable us to appreciate better the implications for health and health policy of currently observed trends, and the likely impact of fairly certain future trends, such as the ageing of the population, the continued spread of HIV/AIDS in many regions, and the continuation of the epidemiological transition in developing countries. The results depend strongly on the assumption that future mortality trends in poor countries will have a relationship to economic and social development similar to those that have occurred in the higher-income countries.

Air pollution and lung cancer risks in China--a meta-analysis

Lung cancer is a serious health problem in China, as in the rest of the world. Many studies have already proved that air pollution as well as other environmental factors can increase the risk of lung cancer. Based on epidemiological studies carried out in China, this paper proposes odds ratios (OR) to evaluate the risk of lung cancer from indoor air pollution for the Chinese population by applying the method of meta-analysis. For domestic coal use for heating and cooking, the pooled OR values are 1.83 (95% CI: 0.62-5.41) and 2.66 (1.39-5.07) for women and both sexes, respectively. For indoor exposure to coal dust, the OR values are 2.52 (95% CI: 1.94-3.28) and 2.42 (1.62-3.63) for women and both sexes, respectively. Cooking oil vapor is another factor increasing lung cancer risk. The OR values are 2.12 (95%CI: 1.81-2.47), 1.78 (1.50-2.12) and 6.20 (2.88-13.32) for nonsmoking women, women, and both sexes, respectively. Regarding environmental tobacco smoke, the pooled OR values are 1.70 (95% CI: 1.32-2.18) and 1.64 (1.29-2.07) for nonsmoking women and both sexes, respectively. Funnel plots with statistical test have been applied to examine the publication bias, and the results implied that the analysis of coal consumption and cooking oil pollution might be affected by publication bias. The meta-analysis results confirm the association between lung cancer and indoor air pollution for the Chinese population.

Tobacco smoke overload and ethnic, state, gender, and temporal cancer mortality disparities in Asian-Americans and Pacific Islander-Americans

BACKGROUND

Asians and Pacific Islanders (APIs) are important populations nationally and globally. So we assessed cumulative tobacco smoke overexposure (smoke overload)/cancer mortality associations across states, ethnicities, years, and genders among API-Americans.

METHODS

Death rates were adjusted to the 2000 United States age standard, lung cancer death rates used as a smoke overload bio-index, and lung/non-lung cancer death rate linear regressions run. Cancer death rate smoking-attributable fractions (SAFs) are equal to 1--estimated unexposed rate/observed rate.

RESULTS

The two lowest smoke overload and non-lung cancer death rates were in South Asian (Indo)-Californian females and males. The highest were in Korean-Californian males. Non-lung cancer death rates were tightly and steeply associated with smoke overload across ethnicity, state, year, or gender. Cancer death rate smoking-attributable fractions ranged from 0 in female and 6% in male Indo-Californians, to 39% in female and 57% in male API-Americans in 2002, to 71% in Korean-Californian and 69% in API Hawaiian males.

DISCUSSION

Many API American cancer death rate disparities across genders, ethnicities, states, or years can be explained by smoke overload disparities. Tobacco control may greatly reduce cancer death rates and disparities among API-Americans and, likely, others.

Significance of ammonium compounds on nicotine exposure to cigarette smokers

The tobacco industry publicly contends that ammonia compounds are solely used as tobacco additive for purposes of tobacco flavoring, process conditioning and reduction of its subjective harshness and irritation. However, neither objective scientific reports, nor the contents of a large number of internal tobacco company documents support this contention. The present review focuses on the hypothesis that addition of ammonium compounds to tobacco enhances global tobacco use due to smoke alkalization and enhanced free-nicotine nicotine exposure. Obviously, ammonia enhances the alkalinity of tobacco smoke. Consequently, the equilibrium shifts from non-volatile nicotine salts to the volatile free base that is more readily absorbed from the airways. The observed change in the kinetics of nicotine (i.e., shorter t(1/2) and higher c(max)) after ammoniation is, however, predominantly due to the higher concentration of nicotine in the smoke, rather than to an increase in the absorption rate of free-base nicotine in the respiratory tract. Although several findings support the hypothesis, additional studies are required and suggested to provide a proper, objective and independent scientific judgment about the effect of tobacco ammoniation on nicotine bioavailability. Scientific and public awareness of the effects of tobacco-specific ammonia compounds may stimulate global control, legislation and restriction of their use in cigarette manufacture.

Policy lessons from comparing mortality from two global forces: international terrorism and tobacco

Background

The aim of this study was to compare the mortality burdens from two global impacts on mortality: international terrorism and the major cause of preventable death in developed countries – tobacco use. We also sought to examine the similarities and differences between these two causes of mortality so as to better inform the policy responses directed at prevention.

Methods

Data on deaths from international terrorism were obtained from a US State Department database for 1994–2003. Estimates for tobacco-attributable deaths were based on Peto et al 2003. The countries were 37 developed and East European countries.

Results and discussion

The collective annualized mortality burden from tobacco was approximately 5700 times that of international terrorism. The ratio of annual tobacco to international terrorism deaths was lowest for the United States at 1700 times, followed by Russia at 12,900 times. The tobacco death burden in all these countries was equivalent to the impact of an 11 September type terrorist attack every 14 hours.

Different perceptions of risk may contribute to the relative lack of a policy response to tobacco mortality, despite its relatively greater scale. The lack is also despite tobacco control having a stronger evidence base for the prevention measures used.

Conclusion

This comparison highlights the way risk perception may determine different policy responses to global forces causing mortality. Nevertheless, the large mortality differential between international terrorism and tobacco use has policy implications for informing the rational use of resources to prevent premature death.

Addiction – who is not affected?

Addiction and addiction-related behaviour increased during the past decades. Several substances with psychoactive attributes, like opioids, cocaine or alcohol, can lead to dependence with physical and/or mental symptoms. In addition to substance-related addiction, non-substance-related dependence requires special attention. Increasing numbers of workaholics and patients suffering from internet-addiction, gambling or eating-disorders can be observed. To meet international treatment standards for addiction, diversification of therapy is necessary and, additionally, gender-related aspects in development and treatment of dependence and addiction-related behaviour are essential for state-of-the-art therapy of this patient population.

Role of smoking in global and regional cancer epidemiology: current patterns and data needs

Although smoking is widely recognized as a major cause of cancer, there is little information on how it contributes to the global and regional burden of cancers in combination with other risk factors that affect background cancer mortality patterns. We used data from the American Cancer Society's Cancer Prevention Study II (CPS-II) and the WHO and IARC cancer mortality databases to estimate deaths from 8 clusters of site-specific cancers caused by smoking, for 14 epidemiologic subregions of the world, by age and sex. We used lung cancer mortality as an indirect marker for accumulated smoking hazard. CPS-II hazards were adjusted for important covariates. In the year 2000, an estimated 1.42 (95% CI 1.27-1.57) million cancer deaths in the world, 21% of total global cancer deaths, were caused by smoking. Of these, 1.18 million deaths were among men and 0.24 million among women; 625,000 (95% CI 485,000-749,000) smoking-caused cancer deaths occurred in the developing world and 794,000 (95% CI 749,000-840,000) in industrialized regions. Lung cancer accounted for 60% of smoking-attributable cancer mortality, followed by cancers of the upper aerodigestive tract (20%). Based on available data, more than one in every 5 cancer deaths in the world in the year 2000 were caused by smoking, making it possibly the single largest preventable cause of cancer mortality. There was significant variability across regions in the role of smoking as a cause of the different site-specific cancers. This variability illustrates the importance of coupling research and surveillance of smoking with that for other risk factors for more effective cancer prevention.

Targeting the Epigenome for the Treatment and Prevention of Lung Cancer

Alterations in chromatin structure resulting from aberrant DNA methylation and perturbations of the histone code profoundly influence gene expression during pulmonary carcinogenesis. Recent studies indicate that DNA demethylating agents and histone deacetylase (HDAC) inhibitors synergistically induce gene expression and apoptosis in cultured lung cancer cells, and prevent lung cancer development in animals following exposure to tobacco carcinogens. Preliminary clinical trials have established proof of principle regarding the use of DNA demethylating agents and HDAC inhibitors for enhancing immunogenicity and apoptosis of lung cancer cells, and have revealed the complexities concerning the mechanisms by which chromatin remodeling agents mediate antitumor effects in vivo. These data support additional investigations pertaining to the epigenetics of lung cancer, and the evaluation of chromatin remodeling agents for the treatment and prevention of this disease.

Role of Smoking in Global and Regional Cardiovascular Mortality

Background— Smoking is a major cause of cardiovascular disease mortality. There is little information on how it contributes to global and regional cause-specific mortality from cardiovascular diseases for which background risk varies because of other risks.

Method and Results— We used data from the American Cancer Society’s Cancer Prevention Study II (CPS II) and the World Health Organization Global Burden of Disease mortality database to estimate smoking-attributable deaths from ischemic heart disease, cerebrovascular disease, and a cluster of other cardiovascular diseases for 14 epidemiological subregions of the world by age and sex. We used lung cancer mortality as an indirect marker for accumulated smoking hazard. CPS-II hazards were adjusted for important covariates. In the year 2000, an estimated 1.62 (95% CI, 1.27 to 2.04) million cardiovascular deaths in the world, 11% of total global cardiovascular deaths, were due to smoking. Of these, 1.17 million deaths were among men and 450 000 among women. There were 670 000 (95% CI, 440 000 to 920 000) smoking-attributable cardiovascular deaths in the developing world and 960 000 (95% CI, 770 000 to 1 200 000) in industrialized regions. Ischemic heart disease accounted for 54% of smoking-attributable cardiovascular mortality, followed by cerebrovascular disease (25%). There was variability across regions in the role of smoking as a cause of various cardiovascular diseases.

Conclusions— More than 1 in every 10 cardiovascular deaths in the world in the year 2000 were attributable to smoking, demonstrating that it is an important preventable cause of cardiovascular mortality.

Tobacco attributable deaths in South Africa

BACKGROUND

In mid 1998, a question "Was the deceased a smoker five years ago?" was introduced on the newly revised South African death notification form.

DESIGN

A total of 16,230 new death notification forms from 1998 have been coded, and comparison of the prevalence of smoking among those who died of different causes was used to estimate, by case-control comparisons, tobacco attributed mortality in South Africa. Cases comprised deaths from causes known (from other studies) to be causally associated with smoking, and controls comprised deaths from medical conditions expected to be unrelated to smoking. Those who died from external causes, and from diseases strongly related to alcohol consumption, were excluded.

SUBJECTS

Reports were available from 5340 deceased adults (age 25+), whose smoking status was given by a family member.

RESULTS

Significantly increased risks were found for deaths from tuberculosis (odds ratio (OR) 1.61, 95% confidence interval (CI) 1.23 to 2.11), chronic obstructive pulmonary disease (COPD) (OR 2.5, 95% CI 1.9 to 3.4), lung cancer (OR 4.8, 95% CI 2.9 to 8.0), other upper aerodigestive cancer (OR 3.0, 95% CI 1.9 to 4.9) and ischaemic heart disease (OR 1.7, 95% CI 1.2 to 2.3).

CONCLUSION

If smokers had the same death rate as non-smokers, 58% of lung cancer deaths, 37% of COPD deaths, 20% of tuberculosis deaths, and 23% of vascular deaths would have been avoided. About 8% of all adult deaths in South Africa (more than 20 000 deaths a year) were caused by smoking.

Regional, disease specific patterns of smoking-attributable mortality in 2000

BACKGROUND

Smoking has been causally associated with increased mortality from several diseases, and has increased considerably in many developing countries in the past few decades. Mortality attributable to smoking in the year 2000 was estimated for adult males and females, including estimates by age and for specific diseases in 14 epidemiological subregions of the world.

METHODS

Lung cancer mortality was used as an indirect marker of the accumulated hazard of smoking. Never-smoker lung cancer mortality was estimated based on the household use of coal with poor ventilation. Estimates of mortality caused by smoking were made for lung cancer, upper aerodigestive cancer, all other cancers, chronic obstructive pulmonary disease (COPD), other respiratory diseases, cardiovascular diseases, and selected other medical causes. Estimates were limited to ages 30 years and above.

RESULTS

In 2000, an estimated 4.83 million premature deaths in the world were attributable to smoking, 2.41 million in developing countries and 2.43 million in industrialised countries. There were 3.84 million male deaths and 1.00 million female deaths attributable to smoking. 2.69 million smoking attributable deaths were between the ages of 30-69 years, and 2.14 million were 70 years of age and above. The leading causes of death from smoking in industrialised regions were cardiovascular diseases (1.02 million deaths), lung cancer (0.52 million deaths), and COPD (0.31 million deaths), and in the developing world cardiovascular diseases (0.67 million deaths), COPD (0.65 million deaths), and lung cancer (0.33 million deaths). The share of male and female deaths and younger and older adult deaths, and of various diseases in total smoking attributable deaths exhibited large inter-regional heterogeneity, especially in the developing world.

CONCLUSIONS

Smoking was an important cause of global mortality in 2000, affecting a large number of diseases. Age, sex, and disease patterns of smoking-caused mortality varied greatly across regions, due to both historical and current smoking patterns, and the presence of other risk factors that affect background mortality from specific diseases.

Prevalence of smoking in 8 countries of the former Soviet Union: results from the living conditions, lifestyles and health study

OBJECTIVES

We sought to provide comparative data on smoking habits in countries of the former Soviet Union.

METHODS

We conducted cross-sectional surveys in 8 former Soviet countries with representative national samples of the population 18 years or older.

RESULTS

Smoking rates varied among men, from 43.3% to 65.3% among the countries examined. Results showed that smoking among women remains uncommon in Armenia, Georgia, Kyrgyzstan, and Moldova (rates of 2.4%-6.3%). In Belarus, Ukraine, Kazakhstan, and Russia, rates were higher (9.3%-15.5%). Men start smoking at significantly younger ages than women, smoke more cigarettes per day, and are more likely to be nicotine dependent.

CONCLUSIONS

Smoking rates among men in these countries have been high for some time and remain among the highest in the world. Smoking rates among women have increased from previous years and appear to reflect transnational tobacco company activity.

Characteristics of cigarette smoking and quitting among university students in Syria

BACKGROUND

No study to date in Syria has documented the smoking and quitting characteristics in a representative sample of university students, and this study aims to fill this void.

DESIGN

In 2003, a cross-sectional survey was carried out among students at Aleppo University using an interviewer-administered questionnaire. Overall, 587 students participated in the study (278 males, 309 females; mean age, 21.8 +/- 2.1 years; response rate, 98.8%). Experiences and attitudes related to smoking and quitting were assessed for two popular forms of tobacco use in Syria-cigarettes and narghile (waterpipe).

RESULTS

Current cigarette smoking was reported by 30.9% of male and 7.4% of female students and daily smoking by 24.8% of male and 5.2% of female students. Narghile smoking was seen among 25.5% of men and 4.9% of women, mostly on an occasional basis. More than half of current smokers (56%) believed they could quit cigarettes, 75.2% were interested in quitting, and 78% of those had made a quit attempt in the past year. Important correlates of cigarette smoking among students were being older, male, and smoking narghile, while being older and from a poorer family were associated with increased interest in quitting. Interestingly, peers' smoking was associated with current smoking among students, but inversely with their willingness to quit.

CONCLUSIONS

Cigarette smoking is mainly a problem of male students, whose narghile smoking is likely to be dramatically increasing as well, sometimes practiced as a substitute for cigarettes. The findings that most smokers in this sample are interested in quitting smoking and have tried unsuccessfully to do so indicate that cessation support for youths in this country is urgently needed.

The global epidemic of tobacco and cancer

OBJECTIVES

To provide a global context for understanding the epidemic of tobacco-induced disease, and the need for nursing action.

DATA SOURCES

International cancer and tobacco statistics; published articles.

CONCLUSION

Tobacco use is a global problem and a significant issue for cancer control. The efforts of health professionals, especially those concerned about cancer, are needed to confront this epidemic.

IMPLICATIONS FOR NURSING PRACTICE

Worldwide action of nurses, the largest group of health professionals, is critical in preventing tobacco use, helping with tobacco cessation, and decreasing exposure to second-hand smoke.

Communicating risks at the population level: application of population impact numbers

Communicating population risk to policy makers and the public is important, but traditional epidemiological measures of risk are difficult to understand. PIN-ER-t, a measure of the population impact of risk factors, is simpler to understand and hence may be useful

Estimates of global mortality attributable to smoking in 2000

BACKGROUND

Smoking is a risk factor for several diseases and has been increasing in many developing countries. Our aim was to estimate global and regional mortality in 2000 caused by smoking, including an analysis of uncertainty.

METHODS

Following the methods of Peto and colleagues, we used lung-cancer mortality as an indirect marker for accumulated smoking risk. Never-smoker lung-cancer mortality was estimated based on the household use of coal with poor ventilation. Relative risks were taken from the American Cancer Society Cancer Prevention Study, phase II, and the retrospective proportional mortality analysis of Liu and colleagues in China. Relative risks were corrected for confounding and extrapolation to other regions.

RESULTS

We estimated that in 2000, 4.83 (uncertainty range 3.94-5.93) million premature deaths in the world were attributable to smoking; 2.41 (1.80-3.15) million in developing countries and 2.43 (2.13-2.78) million in industrialised countries. 3.84 million of these deaths were in men. The leading causes of death from smoking were cardiovascular diseases (1.69 million deaths), chronic obstructive pulmonary disease (0.97 million deaths), and lung cancer (0.85 million deaths).

INTERPRETATION

Smoking was an important cause of global mortality in 2000. In view of the expected demographic and epidemiological transitions and current smoking patterns in the developing world, the health loss due to smoking will grow even larger unless effective interventions and policies that reduce smoking among men and prevent increases among women in developing countries are implemented.

WHO Framework Convention on Tobacco Control: development of an evidence based global public health treaty

Many health problems require international action, but getting governments to agree on strategies for prevention or treatment is difficult. By making use of scientific evidence on the effects of tobacco, the member states of WHO have negotiated their first global health treaty. If the treaty can be implemented effectively, it could act as a possible model for tackling other health issues