Number of deaths (’000s) in 1998 attributable to tobacco use WHO Region Males Females World Health Report 1999 All member states3, Africa The Americas Eastern Mediterranean Europe1, South-East Asia Western Pacific

Source: Murray CJL, Lopez AD DALYs attributable to tobacco use % of total in Region World Developed Regions Developing Regions

Source: Murray CJL, Lopez AD DALYs attributable to tobacco use % of total in Region Est. Market Economies Former Socialist Econ. of Europe India China Sub-Saharan Africa Latin America & Carib

Murray CJL, Lopez AD ”By 2020, tobacco is expected to cause more premature death and disability than any single disease.”

Why do people smoke? P. Hajek 2001 Initiation - social reasons Maintenance - pharmacological reasons

Smokers have low degree of control over their behaviour P. Hajek 2001 Most smokers say they want to quit Over 95% of smokers rarely if ever go a day without a cigarette Over 97% of quit attempts last <6 months Some 70% resume smoking after a major smoking related health crisis

Are smokers addicted? Are smokers addicted? P.Hajek 2001 Signs of addiction include Continued use despite knowledge of harmful effects Witdrawal symptoms and urges to use the drug during abstinence Failure of attempts to stop

WHO ICD 10 International Classification of Diseases F10-F19 Mental and Behavioural Disorders Due to Psychoactive substance use F10 Disorders resulting from use of alcohol F11 Disorders resulting from use of opiods F12 Disorders resulting from use of cannabinoids F13 Disorders resulting from use of sedatives or hypnotics F14 Disorders resulting from use of cocaine F15 Disorders resulting from use of other stimulants F16 Disorders resulting from use of hallucinogens F17 Disorders resulting from use of tobacco F18 Disorders resulting from use of volatile solvents F19 Disorders resulting from multiplw drug use and use of other psychoactive substances

Intervention strategies for reduction of tobacco-related death and disability Decreasing onset of tobacco use Increasing cessation Finding less harmful kinds of tobacco use

Less harmful tobacco use ”Light” cigarettes ? Generally no benefit. Low nicotine yield may even increase health risks unless tar/nicotine ratio is kept extra low Smokeless tobacco ? Most kinds of smokeless tobacco involve severe health risks. However, Swedish ”snus” (a special kind of moist oral snuff) has been recognized as substantially less harmful than smoking

Intervention to decrease onset Potential: In principle it represents a long term solution Difficulties: It cannot yield an appreciable reduction of mortality during the nearest 40 years - only later, when today’s young people reach ages >55 Social pressure to smoke can be very strong and intervention programmes have limited success

Intervention to increase cessation Potential: Mortality reduction occurs quite rapidly after successful intervention Widespread cessation contributes to a social climate that favours prevention of onset Difficulties: Smokers must be given both: - motivation to quit, and - support to overcome their dependence

Three intervention scenarios as basis for: Projections of premature tobacco deaths for periods and Peto R. et al 1998 No intervention (current trends persisting) Intervention to decrease onset (halving uptake of smoking by 2020) Intervention to increase cessation (halving global cigarette consumption by 2020)