Part One
The Scale of the Smoking Problem
A Global Overview
1.1 Tobacco is the single most important avoidable cause of chronic ill health and premature death in developed countries, where it now causes a quarter of all the deaths in middle age, with maximum mortality among males and rising mortality among females. In developing countries many men now smoke, and mortality from tobacco is increasing. Worldwide, if current smoking patterns persist, then annual tobacco deaths will increase from 3 million in the early 1990s (10% of all adult deaths) to 10 million by the late 2020s.4
1.2 The Health Education Authority (HEA) recently estimated that there were 120,000 deaths attributable to smoking in 1995 in the United Kingdom.2 The British Regional Heart Study reported that men who have never smoked have a 78% chance of reaching 73 years of age whereas those who start smoking by the age of 20 and never stop have only a 42% chance.5 The 40 year prospective study of male British doctors, started in 1951, indicated that the hazards of prolonged tobacco use are greater than was thought to be the case 20 years ago.6 Figure 1, based on the whole study, shows the effects on survival to age 70 and to age 85.3 The evidence since 1971 indicates almost a three-fold difference in mortality during middle age between smokers and non-smokers.
Figure 1*: Effect of cigarette smoking on survival to age 70 and to age 85, in 40-year prospective study of male British doctors Source: Doll, Peto et al, 1994
Graphic to follow...
*Reproduced with permission.
1.3 A UK study of over 10,000 survivors from heart attacks, published in August 1995, showed that smokers in their thirties and forties have five times as many heart attacks as non-smokers.7 (Figure 2)
Figure 2*: Ratio of heart attack rates: U.K. smokers vs. non-smokers of the same age
Graphic to follow...
*Reproduced with permission.
1.4 In Great Britain, there was a reduction in the number of adult cigarette smokers (aged 16 and over) from 45% of the population in 1974 to 27% in 1994 but an increase to 28% in 19961 The decline has been confined to adults aged 35 and over. There has been little change since the early 1980s in smoking prevalence in children aged under 16 years, but the 1996 Office for National Statistics' (ONS) figures showed an increase. (See para. 1.19 below). The smoking habit is initiated in the early teens and by the age of 16 a third of all young people, male or female, are smoking at least one cigarette a week. A major trend in many developed countries is the rise in deaths caused by smoking among women. In Scotland lung cancer has overtaken breast cancer as the leading cause of female death from malignant disease, and the same has happened in North America.
1.5 In the United States tobacco use kills more than 400,000 people each year. This figure is more than the combined deaths each year from AIDS, car accidents, alcohol, homicides, illegal drugs, suicides and fires.8 It has been estimated that on average, of one thousand 20 year olds in the United States who smoke cigarettes regularly, about six will die from homicide, about 12 from motor vehicles, about 250 will be killed by smoking in middle age and another 250 in old age.3 The same estimation of current average risks for one thousand UK 20 year olds who smoke cigarettes regularly is that about one will die from homicide, six from motor vehicles and 250 will be killed by smoking in middle age and 250 in old age.3 ( Middle age is defined as 35 to 69 years).
1.6 There is estimated to be over a billion smokers in the world today, with almost one third of them living in China. The number of cigarettes consumed per adult each year in China rose from 700 in 1970 to 2000 in 1990/92 (almost all of which are smoked by men.). By 1985 sales of cigarettes had doubled over 30 years in a number of developed countries. Tobacco consumption has also increased in certain European countries (France, Germany, Austria, Denmark, Sweden, Greece, Italy, Spain and Portugal) and in Japan9 but has decreased in others (United Kingdom, Finland, The Netherlands, Switzerland) and in Australia, Canada, and North America.
1.7 Cigarettes were responsible for about 1.2 million deaths in the European Region of the World Health Organisation in 1995, almost three quarters of a million of which occurred in middle age (35 - 69 years).3 The percentage of male deaths attributable to smoking is substantial everywhere, with the highest proportions in Central and Eastern Europe. Among women, the percentage varies more widely, being high in the UK but very low in countries where the increase in female smoking is only recent.
1.8 The British Medical Bulletin on Tobacco and Health,9 published in 1996, estimated the number of deaths attributable to smoking in forty developed countries and calculated that in 1990 smoking accounted for 35% of all deaths in middle aged males (35-69 years of age). In a monograph3 published in 1994, Peto and others calculated that the average loss of life expectancy for all cigarette smokers in the developed world who die from smoking related diseases is about 16 years. For those who die in middle age (35-69 years) the figure is 22 years and for those killed by tobacco at older ages the figure is 8 years. The proportion of female deaths in middle age that are attributable to tobacco is now approaching the male figure in many countries where women have smoked cigarettes regularly for several decades. The large increases in numbers of women smoking in countries such as France, the Netherlands and Spain are expected to result in substantial rises in female mortality early in the next century.
1.9 The increasing prevalence of smoking in third world countries and in eastern Europe is expected to give rise to increasing numbers of deaths worldwide in the early decades of the next century. It is difficult to give precise figures but, if current smoking patterns persist, the current estimate of three million deaths annually in the world as a whole is likely to rise to 10 million a year in about 30 years' time.3
1.10 Many poor countries have seen increasing male tobacco consumption and limited regulatory measures. For example, the US Centres for Disease Control and Prevention show smoking has risen in sub-Saharan Africa where cheap brands are available and tobacco companies are using intensive advertising and marketing campaigns, sponsoship of events and cigarette price wars. (Lancet 13.9.97)
The Health of the Nation
1.11 In 1992, the previous Government's white paper entitled The Health of the Nation10 set a National Target for England to reduce the death rate from lung cancer in people under the age of 75 by at least 30% in men and at least 15% in women by 2010 (Baseline 1990). There were four additional targets for reduction of risk factors:
- to reduce the prevalence of cigarette smoking in men and women aged 16 and over to no more than 20% by the year 2000 (a reduction of at least 35% in men and 29% in women, from prevalences in 1990 of 31% and 28% respectively);
- in addition to the overall reduction in prevalence, at least a third of women smokers to stop smoking at the start of their pregnancy by the year 2000;
- to reduce the consumption of cigarettes by at least 40% by the year 2000 (from 98 billion manufactured cigarettes per year in 1990 to 59 billion);
- to reduce smoking prevalence in 11 to 15 year olds by at least 33% by 1994 (from about 8% in 1988 to less than 6%).
1.12 The white paper also set out some specific policy commitments to help achieve these targets in five main areas: price and accessibility; health education and cessation advice; controls on advertising and promotion of non-smoking; and improving scientific understanding.
Progress towards Health of the Nation targets
1.13 The lung cancer mortality rate for men fell by an estimated 13.9% over the four years since the start of the Health of the Nation strategy. Over the same period the mortality rate for women fell by only 2.5%. These data should be interpreted with caution because of the latent period for onset of cancer.
1.14 Preliminary figures from the 1996 General Household Survey1 (GHS) data published in November 1997 show that, for the first time since smoking questions were included in 1972, the prevalence of cigarette smoking has increased for both men and women. Between 1990 and 1994 the percentage of men smoking cigarettes fell from 31% to 28% and that for women fell from 28% to 26%. In 1996, 29% of men and 28% of women smoked cigarettes, which is a return to 1992 figures. The increase was only statistically significant for women aged 25 - 34 (up from 30% in 1994 to 34% in 1996.) In recent years the fall in smoking prevalence among men and women has been levelling out, but it is not known whether the new figures indicate a trend or a short term fluctuation.
1.15 The General Household Survey also demonstrates that smoking prevalence is closely linked with socio-economic status. In the period between 1974 and 1994 smoking prevalence in professional groups fell by a half, but in unskilled manual workers the fall was only a third. This means that, by 1994, unskilled workers were two to three times more likely to smoke than professionals.
1.16 The 1995 Infant Feeding Survey (IFS)11, which is retrospective (ie seeking information after the pregnancy) and uses postal questionnaires, monitors smoking in pregnancy and showed that the Health of the Nation year 2000 target may have been met ahead of time. The percentage of pregnant smokers who gave up during pregnancy increased from 24% in 1985 to 33% in 1995. Additionally, 47% smoked fewer cigarettes. The IFS shows that people in lower socioeconomic groups were more likely to smoke before pregnancy and less likely to give up smoking during pregnancy than women in higher groups. For example, 45% of women with partners in non-manual occupations gave up smoking during pregnancy compared with 32% of women with partners in manual occupations and 24% of women with no partner.
1.17 The Health Education Authority survey “Trends in Smoking and Pregnancy 1992 - 199712 is prospective and uses a quota sample to interview pregnant women. This survey gives more information of value, highlighting particular areas for concern which are not identified in IFS11 questionnaires. For example, more than twice as many women with partners in the unemployed and manual groups smoked compared with those with partners in the non manual groups (39% and 15% respectively), and only one in four pregnant women gave up smoking during pregnancy (26% - this falls short of the Health of the Nation target). The percentage of women who recalled advice from a professional was 49% in the HEA study and 85% in the IFS. This discrepancy could be explained by the increasing likelihood of receiving advice as the pregnancy progresses which indicates that women may not be receiving advice until later in the pregnancy. One third of those receiving advice from general practitioners (GPs) and almost one half who received advice from midwives recall being advised to cut down consumption rather than give up smoking.
1.18 Provisional figures for the year to June 1996 show that 81.2 billion cigarettes were released for home consumption. This represents an annual reduction of roughly 3.1% from the 1990 baseline of 98 billion ie a total reduction of just over 17% in five and a half years. This trend, if continued, would fall short of the target of 40% over 10 years. The figures include an estimate of EU imports for the period following the establishment of the European single market on 1 January 1993.
1.19 Headline figures for 1996, released by the Office for National Statistics (ONS)13 in July 1997, show that the target for smoking prevalence amongst 11 to 15 year olds was not only missed but the prevalence level actually rose to 13%. In England in 1996, 11% of boys and 15% of girls were regular smokers. The prevalence figure for 11 to 15 year olds was 12% in 1994 and although the increase is not statisically significant it continues the recent upward trend. Very few children are smokers when they start secondary school, but at the time they reach the fifth year, when they are for the most part 15 years old, about three out of every ten smoke at least one cigarette a week. For 1996 the percentages for male regular smokers at ages 11, 12, 13, 14, and 15 were 1, 2, 8, 13 and 28. For females the percentages for the same ages were: 0, 4, 11, 24 and 33.12
Wales - Targets and Progress
1.20 The Strategic Intent and Direction for the NHS in Wales14 set a target to reduce the mortality rate from lung cancer in those aged 45 - 64 by at least 15% by the year 2002, from a baseline of 124 per 100,000 in men and 44 per 100,000 in women in 1985. Health for All in Wales15 set the following targets for smoking:
- to reduce the proportion of men aged 18-64 who smoke daily to 20%, and of women to 17%, by the year 2000, from 35% in men and 30% in women in 1985.
- to reduce the proportion of 15 year old boys who smoke at least weekly to 11%, and of girls to 14%, by the year 2000, from 15% in boys and 20% in girls in 1986.
1.21 The mortality rate from lung cancer for men aged 45 - 64 fell steadily by approximately one third between 1985 and 1995. There had been about a 10% reduction for women, but little change from 1992 onwards. Health Promotion Wales surveys16 showed that by 1996 daily smoking amongst men aged 18 - 64 had fallen to 28%, and amongst women to 26%. For 15 year olds, however, the proportion of boys smoking at least weekly had risen to 23%, and girls to 29%.
1.22 In 1997, new health gain targets were announced in Wales, under the New Strategic Plans initiative.17 These are:
- to reduce European standardised mortality rate for lung cancer in men under the age of 75 by at least 54% by 2010 (from 49.2 per 100,000 in 1995 to no more than 22.6 in 2010).
- to reduce European standardised mortality rate for lung cancer in women under the age of 75 by at least 21% by 2010 (from 23.0 per 100,000 in 1995 to no more than 18.2 in 2010).
- to reduce the proportion of adults age 18 to 64 who smoke (daily and occasionally) to no more than 20% for both men and women by 2002 (from 31.5% in men and 28.1% in women in 1993).
- to reduce the proportion of 15 year old children who smoke (at least weekly) to no more than 16% for boys and 20% for girls (from 23% in boys and 29% in girls in 1996).
- to increase the proportion of women who give up smoking during their pregnancy to at least 33%.
Scotland - Targets and Progress
1.23 In 1992 the policy statement “Scotland's Health: A Challenge to us all”18 reaffirmed the national targets in relation to smoking set the previous year in “Health Education in Scotland: A National Policy Statement”.19 These targets were to achieve a 30% reduction in the prevalence of smoking in those aged 12-24 years (from 30% to 21%) and a 20% reduction in those aged 25-65 years (from 40% to 32%) between 1986 and 2000.
1.24 In the 1995 Scottish Health Survey20 interviews were conducted on a random sample of 7932 persons aged 16-64 years. Overall 34% of men and 36% of women were self-reported current smokers. Serum cotinine analysis suggested a degree of under-reporting, giving an adjusted estimate of 43% of men and 38% of women. The prevalence of self-reported smoking in 25-65 year olds was 35% and in 16-24 year olds was 34%.
1.25 The survey showed an association between social class and smoking; 23% of men and 22% of women in Social Classes I and II were self-reported smokers, compared with 49% in respect of both sexes in social classes IV and V.
1.26 The ONS biennial survey of smoking among secondary school children in Scotland21 has shown no significant improvement in smoking levels in 12-15 year olds between 1982 and 1996. In 1996 22% of boys and 23% of girls in this age group were regular or occasional smokers.
Northern Ireland - Targets and Progress
1.27 The Regional Strategy for the Northern Ireland Health and Personal Social Services 1992-199722 set targets to increase the proportion of the population aged 12-64 who do not smoke cigarettes from 70% to 75% and to increase the proportion of children who have not started to smoke. In 1994 a specific target to increase the percentage of 15 year olds who do not smoke to 80% by 1997 was added.
1.28 The Continuous Household Survey 1994/9523 showed that the proportion of the population who do not smoke cigarettes had increased to 72%. The 1994 Heath Behaviour of School Children in Northern Ireland Survey24 found that 17% of 11-15 year olds were smokers, 13% of whom smoked at least once weekly. By fifth form 26% of girls and 22% of boys were smoking at least once weekly. Comparison with results of surveys since 1983 show that there has been little change in the proportion of children who smoke.
1.29 The New Northern Ireland Strategy “Regional Strategy for Health and Social Wellbeing 1997-2002”25 has set new targets for smoking. These are:
By 2002 the proportion of the adult population aged 16+ who do not smoke cigarettes should have increased from 72% to 74%.
By 2002 the proportion of the population aged 11-15 years who do not smoke cigarettes should have increased from 83% to 85%.
Nicotine Addiction
1.30 Over the past decade there has been increasing recognition that underlying smoking behaviour and its remarkable intractability to change is addiction to the drug nicotine.26,27 Nicotine has been shown to have effects on brain dopamine systems similar to those of drugs such as heroin and cocaine,28 and with appropriate reward schedules it functions as a robust reinforcer in animals.29Dependence on nicotine is established early in teenagers' smoking careers,30 and there is compelling evidence that much adult smoking behaviour is motivated by a need to maintain a preferred level of nicotine intake, leading to the phenomenon of nicotine titration, or compensatory smoking in response to lowered nicotine yields.31 People seeking treatment for heroin, cocaine, or alcohol dependence rate cigarettes as hard to give up as their problem drug.32 The aversiveness of nicotine withdrawal is an important factor underlying the failure of many attempts at cessation.
Smoking Related Diseases
1.31 A large number of fatal and life-threatening diseases are caused largely or entirely by smoking. They include chronic obstructive pulmonary disease, vascular diseases at various critical sites and several forms of cancer.
1.32 Chronic Obstructive Pulmonary Disease (COPD) is caused by irreversible and usually progressive limitation of airflow and occurs most usually in the form of chronic bronchitis and emphysema. It is a major cause of disability and premature death. The American Cancer Society (CPS II)33 Study found that cigarette smokers had ten times the risk of dying from COPD than non-smokers; about three-quarters of deaths from this disease were attributable to smoking. In the prospective study of male British doctors6 cigarette smokers had 13 times the risk of dying of the disease compared to non-smokers and again about three quarters of deaths from this disease were attributable to smoking. The results from these two major prospective studies are remarkably consistent. The importance of smoking as a cause of chronic obstructive pulmonary disease is often overlooked yet it contributes a major burden of disease due to smoking.
1.33 The extent of arterial damage induced by smoking is great. Examples of serious arterial diseases related to smoking include coronary artery disease and heart attacks, aortic aneurysms which can lead to sudden death,34 carotid artery disease which can lead to strokes35 and peripheral vascular disease which, in the lower limbs, can lead to severe pain in the leg on walking and may necessitate amputation.36 Recent data show that smoking causes more rapid expansion of aortic aneurysm.37
1.34 Smoking causes increased risk of cancers in several sites, pre-eminently the lung, but also several others such as the oral cavity, pharynx, larynx, oesophagus, pancreas and bladder. The association between smoking and certain cancers of the head and neck is discussed in Part Six.
1.35 The following tables, reproduced with permission from the British Medical Bulletin,9 give data on fatal diseases positively associated with smoking from the study of male British doctors and the large American Cancer Society study.
Table 1 Fatal diseases positively associated with smoking - study of male British doctors6
Table 2 Fatal diseases positively associated with smoking - American Cancer Society (CPSII). Men and Women aged 35 years or more
1.36 Smoking in pregnancy causes adverse outcomes notably miscarriage, reduced birth weight for gestation and perinatal death. Where parents continue to smoke after pregnancy there is an increased rate of sudden infant death syndrome.
1.37 The list of other diseases known to be associated with smoking includes cataracts, hip fracture (osteoporosis), and periodontal disease.9
Conclusions
1.38 Smoking is a major cause of illness and death from chronic respiratory diseases, cardiovascular disease, and cancers of the lung and other sites.
1.39 Smoking is the most important cause of premature death in developed countries. It accounts for one fifth of deaths in the UK: some 120,000 deaths a year.
1.40 The avoidance of smoking would eliminate one third of the cancer deaths in Britain and one sixth of the deaths from other causes.
1.41 Smoking prevalence in young people rose between 1988 and 1997 and the downward trend in adult smoking, noted in the UK since 1972, was reversed in 1996.
1.42 A person who smokes regularly more than doubles his or her risk of dying before the age of 65.
1.43 Addiction to nicotine sustains cigarette smoking and is responsible for the remarkable intractability of smoking behaviour.
1.44 Smoking in pregnancy causes adverse outcomes, notably an increased risk of miscarriage, reduced birth weight and perinatal death. If parents continue to smoke after pregnancy there is an increased rate of sudden infant death syndrome.
1.45 Cigarette smoking is an important contributor to health inequalities, being much more common amongst the disadvantaged than the affluent members of society.
Recommendations
1.46 The enormous damage to health and life arising from smoking should no longer be accepted; the Government should take effective action to limit this preventable epidemic.
1.47 The Government should require of the tobacco industry:
- reasonable standards in the assessment of evidence relating to the health effects of the product it sells,
- acceptance that smoking is a major cause of premature death, and
- normal standards of disclosure of the nature and magnitude of the hazards of smoking to their customers, comparable to that expected from other manufacturers of consumer products.
1.48 Independently of specific governmental regulations, tobacco manufacturers should comply with these requirements.
1.49 There is an importance and urgency with the smoking problem that needs to be recognised by both the Government and the public.
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