Smoking
Prevalence of Tobacco Smoking from 2000 to 2020, with countries grouped from the highest to lowest drops in percent prevalence
- Burning Issues: The Global State of Tobacco Harm Reduction 2020
Rates of smoking have fallen for both men and women largely due to greater public awareness of the importance of a healthier lifestyle, as well as the introduction of various tobacco control measures including advertising bans, smoke-free environments, and higher taxation. Nevertheless, reduction in smoking prevalence tends to start plateauing at around 20% of a population, suggesting diminishing returns on tobacco control interventions. In this graphic, we have grouped countries in terms of the drop in the prevalence of current tobacco smoking, from those countries with the highest drop in prevalence to those with the lowest drop. Across all groups there tends to be a levelling at around 20%.
See also p.32 of the report: Burning Issues: The Global State of Tobacco Harm Reduction 2020
Countries With the Highest Levels of Mortality Attributable to Smoking Tobacco
- Burning Issues: The Global State of Tobacco Harm Reduction 2020
Deaths from smoking remain high. This is linked both to the current prevalence of smoking, and the legacy of smoking in previous years. There are 27 countries where 20% or more of deaths are attributable to smoking, as shown in this graphic. In addition to the huge human toll of illness and death there is the enormous cost to the global economy. Considering both direct costs of hospital care and medication, and indirect costs of lost productivity, it has been calculated that the annual global cost of smoking-related disease and death amounts to $1.4 trillion. Extrapolated to the end of the century, the figure comes to $112 trillion. According to the 2019 World Bank data, this is $24 trillion more than current annual global GDP.
See also p.33 of the report: Burning Issues: The Global State of Tobacco Harm Reduction 2020
Prevalence of Current Smoking Cigarettes and Current Vaping
- Burning Issues: The Global State of Tobacco Harm Reduction 2020
Overall, as a percentage of the total adult population, current use of vaping devices in different countries ranges between 1% and 7%. As shown by this graphic there are eight countries where the prevalence of vaping is 3% or more including the UK, United Arab Emirates (UAE), US, France, Iceland, Belgium, the Russian Federation and Malaysia. The average prevalence of current vaping product use is 1.6 % of the adult population in the EU, as found in the EU Eurobarometer survey. A further 13% “used to use them, but no longer do so” or “have tried them once or twice”. 85.6% “have never tried or used them”. Levels of sometime vaping experience range up to 27% of the adult population in Greece, and 20% or above in Estonia, Czech Republic, France, Cyprus, Latvia and Austria. Clearly, there are many smokers who are interested in these products. But there is also a large gap between those who have shown enough interest to have tried vaping at some time, and those who have gone on to currently vape.
See also p.50 of the report: Burning Issues: The Global State of Tobacco Harm Reduction 2020
Trends in Smoking (UK) and E-Cigarette Use (Great Britain)
- Burning Issues: The Global State of Tobacco Harm Reduction 2020
We noted in our previous report the significant rise in vaping and decline in smoking since 2011. Around 7% of the adult population in Great Britain currently vapes, which equates to around 6 million vapers. The year on year increase in vaping is matched by the continuing major reduction in smoking in the UK with under 15% of the adult population currently smoking.
For an up to date assessment of safer nicotine product use in England see: https://gsthr.org/countries/profile/gbr/
See also p.52 of the report: Burning Issues: The Global State of Tobacco Harm Reduction 2020
Changes in the Prevalence of Smoking and Sales of Cigarettes and Snus in Iceland
- Burning Issues: The Global State of Tobacco Harm Reduction 2020
Iceland has witnessed a dramatic decline in smoking to 8.2% in 2019, and has the second lowest adult daily smoking rate in Europe after Sweden. A long-term decline in smoking accelerated in 2007 and again in 2012. Market data show, on a weight-for-weight basis, a continued decline in cigarette sales and an increase in snus sales. Prevalence of adult daily snus use was 3.2% in 2012 rising to 6% in 2019. Prevalence of adult daily e-cigarette use was 3.6% in 2017. It would appear that the uptake of snus and latterly of e-cigarettes has contributed to the long-term decline in smoking. Most significant is that smoking uptake among young people has virtually disappeared with only 3.3% of 18-24 year old smoking, and 0.8% of 16 year olds.
See also p.53 of the report: Burning Issues: The Global State of Tobacco Harm Reduction 2020
Smokers in Billions
- Burning Issues: The Global State of Tobacco Harm Reduction 2020
Globally there are 68 million people vaping, 20 million using heated tobacco products and 10 million using snus or US smokeless. This might look like a success, particularly for vaping and heated tobacco products which are recent introductions, but is it? A bleak assessment would be not yet. 98 million users of safer nicotine products (SNP) is minuscule compared with continued use of combustible products by 1.1 billion smokers. It only amounts to nine SNP users for every 100 smokers and six vapers for every 100 smokers.
Despite the enthusiasm for safer alternatives, the rate of progress in switching from smoking to SNP is slow. There is an urgent need to scale up tobacco harm reduction. What is needed to make this happen is for products to be:
» Available - Regulation and control should be geared to making these products as readily available as other consumer goods, given that independent and internationally agreed products safety standards are in place. So no outright bans, no flavour bans, no regulation as medicinal products and no exorbitant tobacco-style taxation. Instead, are there ways to incentivise both industry and consumers to switch instead of trying to stub out safer nicotine alternatives?
» Affordable - This links to the question of consumers’ ability, especially in lower and middle-income countries, to afford products. A supportive legislative landscape is required, and other obstacles need to be overcome. For example, mobile phones are ubiquitous across Africa with the capacity to charge them up, so affordable, rechargeable vaping devices must be a possibility, if the will is there from the manufacturers.
» Appropriate - Vaping devices might work to replace cigarettes in many countries but won’t be appropriate everywhere and with all communities. There are many nicotine consumers, especially in India and South East Asia, who don’t smoke conventional cigarettes but instead smoke local varieties or use a range of even more dangerous smokeless tobacco products. It would be hugely beneficial from a public health perspective if these dangerous smokeless products were replaced by far safer snus- type smokeless products.
» Acceptable - Public health and commercial marketing strategies would need to account for long-standing social and cultural custom and practice, the nature of the messaging, who is delivering the messages and by what means.
See also p.55 of the report: Burning Issues: The Global State of Tobacco Harm Reduction 2020
Changes in the Prevalence of Smokers and Vapers Among American Youth
- Burning Issues: The Global State of Tobacco Harm Reduction 2020
Cigarette smoking has been falling in the US for many years including among young people. When vaping products began to appear on the market, it was inevitable that some young people would want to experiment. This led to claims from the U.S. Food and Drug Administration (FDA), the Campaign for Tobacco Free Kids (CTFK) and others that vaping was a gateway to smoking as the industry tried to compensate for falling numbers of younger smokers by promoting new products. Yet as the graph shows, cigarette smoking among young people has continued to fall, even while experimentation with vaping devices has been increasing. The goalposts shifted; the claim now from the same bodies is of a vaping “epidemic” among young people which would lead to a future generation of nicotine “addicts”. JUUL certainly attracted a lot of interest from some young people when it launched during 2018-19, while the company itself faced accusations of marketing the device to young adults and selling flavours that appeared to be targeting that same younger audience.
The public, the media and legislators continue to be misled over the prevalence of vaping among young people by the simple trick of conflating ‘ever use’, which could be just once or very infrequent, with ‘use’. However, a study by Allison Glasser and colleagues from New York University (NYU) College of Global Public Health looked at the 2018 National Youth Tobacco Survey of 20,000 middle and high school students and concluded that:
» Over 80 per cent of youth do not use any tobacco product.
» Over 86 per cent don’t vape.
» Most youth who do vape are current or former smokers and many are also vaping THC.
» While youth vaping has increased, this was driven by infrequent use.
» Only very few students vaped who had never smoked.
See also p.81 of the report: Burning Issues: The Global State of Tobacco Harm Reduction 2020
Harm Perceptions of E-Cigarettes Compared With Cigarettes
- Burning Issues: The Global State of Tobacco Harm Reduction 2020
Even in the UK, where the government and public health authorities have taken a world-leading pragmatic approach to tobacco harm reduction and publicised support for switching, the proportion of smokers believing that smoking and vaping are equally harmful has increased from 28% in the last quarter of 2014 to over 52% in the first quarter of 2020. In the first quarter of 2020, a further 21% said that vaping was more harmful than smoking. This means most smokers believe that vaping is as harmful or more harmful than smoking. To quote the latest Public Health England report on vaping in England: “It is of concern that negative beliefs about the harms from vaping might prevent smokers from switching to vaping and they would therefore continue to be exposed to the extremely high levels of harm caused by smoking.”
See also p.98 of the report: Burning Issues: The Global State of Tobacco Harm Reduction 2020
US Government Funding Roundabout
- Burning Issues: The Global State of Tobacco Harm Reduction 2020
The US Government relies on a complicated cascade of financial assistance for its various departments. Money flows downwards from the Department of Health and Human Services (HHS), who in turn have to compete with all the other departments in convincing Congress of the value of their services in the fight for a share of the Federal budget. However, once a budget is secured, agencies within the HHS like the FDA, CDC and National Institutes of Health (NIH) are in competition for a slice of the pie. They all understand there is nothing more effective at loosening the public purse strings than declaring an epidemic that must be tackled.
But these agencies need to prove their case – and this is where a co-dependency cascade begins. The hottest health topic before COVID-19 was the outbreak of vaping-related deaths, which helped solidify the dangers of the alleged epidemic of youth vaping. This was the subject most likely to attract HHS budget holders.
Agencies like the FDA and CDC often consult with and take briefings from a number of long-established, well-funded and influential health advocacy groups. To the public, these groups appear to be generating advice that is based on medical and scientific expertise, in the service of public well-being and absent of any bias. However, groups like the Campaign for Tobacco Free Kids, backed by advocacy-driven research, are in fact acting as moral entrepreneurs. They are generating the marketing and press releases which stimulate public concern.
While the media provide the public megaphone, NGOs engage in the kind of political activism forbidden to government agencies, putting pressure on politicians and legislators to act in the face of public clamour. In fact, politicians and government officials need external allies to give the impression they have responded positively to community concerns; proof they are listening to the people. As Franklin Roosevelt famously said, “OK. You’ve convinced me. Now go out there and bring pressure on me.”
See also p.81 of the report: Burning Issues: The Global State of Tobacco Harm Reduction 2020