Leading cause of death, illness and impoverishment

The tobacco epidemic is one of the biggest public health threats the world has ever faced, killing more than 8 million people a year around the world. More than 7 million of those deaths are the result of direct tobacco use while around 1.2 million are the result of non-smokers being exposed to second-hand smoke.

All forms of tobacco are harmful, and there is no safe level of exposure to tobacco. Cigarette smoking is the most common form of tobacco use worldwide. Other tobacco products include waterpipe tobacco, various smokeless tobacco products, cigars, cigarillos, roll-your-own tobacco, pipe tobacco, bidis and kreteks.

Waterpipe tobacco use is damaging to health in similar ways to cigarette tobacco use. However, the health dangers of waterpipe tobacco use are often little understood by users.

Smokeless tobacco use is highly addictive and damaging to health. Smokeless tobacco contains many cancer-causing toxins and its use increases the risk of cancers of the head, neck, throat, oesophagus and oral cavity (including cancer of the mouth, tongue, lip and gums) as well as various dental diseases.

Over 80% of the 1.3 billion tobacco users worldwide live in low- and middle-income countries, where the burden of tobacco-related illness and death is heaviest. Tobacco use contributes to poverty by diverting household spending from basic needs such as food and shelter to tobacco.

The economic costs of tobacco use are substantial and include significant health care costs for treating the diseases caused by tobacco use as well as the lost human capital that results from tobacco-attributable morbidity and mortality.

In some countries children from poor households are employed in tobacco farming to boost family income. Tobacco growing farmers are also exposed to a number of health risks, including the "green tobacco sickness".

Surveillance is key

Effective monitoring tracks the extent and character of the tobacco epidemic and indicates how best to implement policies. Only 1 in 3 countries, representing 38% of the world's population, monitors tobacco use by repeating nationally representative youth and adult surveys at least once every 5 years.

Key measures to reduce the demand for tobacco

Second-hand smoke kills



Second-hand smoke is the smoke that fills enclosed spaces when people burn tobacco products such as cigarettes, bidis and water-pipes.

There is no safe level of exposure to second-hand tobacco smoke, which causes more than 1.2 million premature deaths per year and serious cardiovascular and respiratory diseases.

Almost half of children regularly breathe air polluted by tobacco smoke in public places, and 65 000 die each year from illnesses attributable to second-hand smoke.

In infants, it raises the risk of sudden infant death syndrome. In pregnant women, it causes pregnancy complications and low birth weight.

Smoke-free laws protect the health of non-smokers and are popular, as they do not harm business and they encourage smokers to quit.

Pictorial health warnings work

Large pictorial or graphic health warnings, including plain packaging, with hard hitting messages can persuade smokers to protect the health of non-smokers by not smoking inside the home, increase compliance with smoke-free laws and encourage more people to quit tobacco use.

Studies show that pictorial warnings significantly increase people's awareness of the harms from tobacco use.

Mass media campaigns can also reduce demand for tobacco by promoting the protection of non-smokers and by convincing people to stop using tobacco.

Bans on tobacco advertising lower consumption

Comprehensive bans on tobacco advertising, promotion and sponsorship can reduce tobacco consumption.

A comprehensive ban covers both direct and indirect varieties of promotion. Direct forms include, among others, advertising on television, radio, print publications, billboards and more recently in various social media platforms. Indirect forms include, among others, brand sharing, brand stretching, free distribution, price discounts, point of sale product displays, sponsorships and promotional activities masquerading as corporate social responsibility programmes.



Taxes are effective in reducing tobacco use

Tobacco taxes are the most cost-effective way to reduce tobacco use and health care costs, especially among youth and low-income people, while increasing revenue in many countries.

The tax increases need to be high enough to push prices up above income growth. An increase of tobacco prices by 10% decreases tobacco consumption by about 4% in high-income countries and about 5% in low- and middle-income countries.

Despite this, introducing high tobacco taxes is a measure that is least implemented among the set of available tobacco control measures.

Tobacco users need help to quit

Studies show that few people understand the specific health risks of tobacco use. However, when smokers become aware of the dangers of tobacco, most want to quit.

Without cessation support only 4% of attempts to quit tobacco will succeed.

Professional support and proven cessation medications can more than double a tobacco user's chance of successful quitting.

Illicit trade of tobacco products must be stopped

The illicit trade in tobacco products poses major health, economic and security concerns around the world. It is estimated that 1 in every 10 cigarettes and tobacco products consumed globally is illicit. The illicit market is supported by various players, ranging from petty traders to big tobacco companies, and in some instances even organized criminal networks involved in arms and human trafficking.

Tax avoidance (licit) and tax evasion (illicit) undermine the effectiveness of tobacco control policies, particularly higher tobacco taxes.

The tobacco industry and others often argue that high tobacco product taxes lead to tax evasion. However, experience from many countries demonstrate that illicit trade can be successfully addressed even when tobacco taxes and prices are raised.

Stopping illicit trade in tobacco products is a health priority and is achievable. But to do so requires improvement of national and sub-national tax administration systems and international collaboration. The WHO FCTC Protocol to Eliminate the Illicit Trade of Tobacco Products (ITP) sets out a range of important measures and interventions to reduce tobacco use and its health and economic consequences.

Novel and emerging nicotine and tobacco products

Heated tobacco products (HTPs)

HTPs are like all other tobacco products, inherently toxic and contain carcinogens. They should be treated like any other tobacco product when it comes to setting policies on HTPs. HTPs produce aerosols containing nicotine and toxic chemicals upon heating of the tobacco, or activation of a device containing the tobacco. Examples include iQOS, Ploom, glo and PAX vaporizers. The aerosols are inhaled by users during a process of sucking or smoking involving a device. They contain the highly addictive substance nicotine, non-tobacco additives and are often flavoured.

In recent years, HTPs have been promoted as ‘reduced harm’ products and/or products that can help people quit conventional tobacco smoking. HTPs expose users to toxic emissions, many of which cause cancer and currently there is not enough evidence to suggest that they are less harmful than conventional cigarettes. There is also insufficient evidence at present on the effects of second-hand emissions produced by HTPs, though the emissions from these products contain harmful and potentially harmful chemicals (1).

E-cigarettes

Electronic nicotine delivery systems (ENDS) and electronic non-nicotine delivery systems (ENNDS), commonly referred to as e-cigarettes, are devices which heat a liquid to create an aerosol which is then inhaled by the user, these may or may not contain nicotine. The main constituents of the solution by volume are propylene glycol, with or without glycerol, and flavouring agents. E-cigarettes do not contain tobacco but are harmful to health and are not safe. However, it is too early to provide a clear answer on the long-term impacts of using them or being exposed to them.

E-cigarettes are particularly risky when used by children and adolescents. Nicotine is highly addictive and young people’s brains develop up to their mid-twenties.

ENDS use increases the risk of heart disease and lung disorders. They also pose significant risks to pregnant women who use them, as they can damage the growing fetus.

Advertising, marketing and promotion of ENDS has grown rapidly, through channels which rely heavily on internet and social media (3). Much of the marketing around these products gives rise to concern about deceptive health claims, deceptive claims on cessation efficacy, and targeting towards youth (especially with the use of flavours).

ENDS/ENNDS should not be promoted as a cessation aid until adequate evidence is available and the public health community can agree upon the effectiveness of those specific products. Where ENDS and ENNDS are not banned, WHO recommends that the products be regulated in accordance with four key objectives:

Prevent initiation of ENDS/ENNDS by non-smokers, minors and vulnerable groups;

Minimize health risks for ENDS/ENNDS users and protect non-users from exposure to their emissions;

Prevent unproven health claims being made about ENDS/ENNDS; and

Protect tobacco control from all commercial and other vested interests related to ENDS/ENNDS, including interests of the tobacco industry (5).

WHO response

The scale of the human and economic tragedy that tobacco imposes is shocking, but it’s also preventable. Big Tobacco – along with all manufacturers of tobacco products – is fighting to ensure the dangers of their products are concealed, but we are fighting back: In 2003, WHO Member States unanimously adopted the WHO Framework Convention on Tobacco Control (WHO FCTC). In force since 2005, it has currently 182 Parties covering more than 90% of the world's population.

The WHO FCTC is a milestone in the promotion of public health. It is an evidence-based treaty that reaffirms the right of people to the highest standard of health, provides legal dimensions for international health cooperation and sets high standards for compliance. Strengthening implementation of the treaty is specifically included in the 2030 Agenda for Sustainable Development Goals (SDG) as Target 3.a.

In 2007, WHO introduced a practical, cost-effective way to scale up implementation of the main demand reduction provisions of the WHO FCTC on the ground: MPOWER. Each MPOWER measure corresponds to at least 1 provision of the WHO Framework Convention on Tobacco Control.

The 6 MPOWER measures are:

M onitor tobacco use and prevention policies

onitor tobacco use and prevention policies P rotect people from tobacco use

rotect people from tobacco use O ffer help to quit tobacco use

ffer help to quit tobacco use W arn about the dangers of tobacco

arn about the dangers of tobacco E nforce bans on tobacco advertising, promotion and sponsorship

nforce bans on tobacco advertising, promotion and sponsorship Raise taxes on tobacco.

WHO has been monitoring MPOWER policies since 2007. For more details on progress made for tobacco control at global, regional and country level, please refer to the series of WHO reports on the global tobacco epidemic. Brazil and Turkey are the only two countries to fully implement all the MPOWER measures at the highest level of achievement.

WHO report on the global tobacco epidemic 2019: Offer help to quit tobacco use is the seventh in a series of WHO reports that tracks the status of the tobacco epidemic and interventions to combat it.

The Protocol to Eliminate Illicit Trade in Tobacco Products requires a wide range of measures relating to the tobacco supply chain, including the licensing of imports, exports and manufacture of tobacco products; the establishment of tracking and tracing systems and the imposition of penal sanctions on those responsible for illicit trade. It also seeks to criminalize actions such as illicit production and cross-border smuggling. The Protocol to Eliminate Illicit Trade in Tobacco Products, the first Protocol to the Convention, was adopted in November 2012 at the fifth session of the Conference of the Parties in Seoul, Republic of Korea, and came into force in September 2018. The Protocol counts 58 Parties, to date.

World No Tobacco Day is celebrated around the world every year on May 31. This yearly celebration informs the public on the dangers of using tobacco, the business practices of tobacco companies, what WHO is doing to fight the tobacco epidemic, and what people around the world can do to claim their right to health and healthy living and to protect future generations. Learn more about the 2020 campaign.

References

(1) iQOS: evidence of pyrolysis and release of a toxicant from plastic

(2) Electronic Cigarette Market by Product Type, Flavor and Distribution Channel – Global Opportunity Analysis and Industry Forecast, 2017–2023

(3) Huang J, Kornfield R, Szczypka G, Emery S. A cross-sectional examination of marketing of electronic cigarettes on Twitter. Tobacco Control. 2014; 23 (suppl 3): iii26-iii30

(4) Electronic Nicotine Delivery Systems and Electronic Non-Nicotine Delivery Systems (ENDS/ENNDS) [Online]. Decision by WHO, Conference of the Parties to the WHO Framework Convention on Tobacco Control, Seventh session, FCTC/COP/7(9), 2016.

(5) Electronic Nicotine Delivery Systems and Electronic Non-Nicotine Delivery Systems (ENDS/ENNDS) [Online]. Decision by WHO, Conference of the Parties to the WHO Framework Convention on Tobacco Control, Seventh session, FCTC/COP/6(9), 2014.



* WHO’s Framework Convention on Tobacco Control defines tobacco products as “products entirely or partly made of the leaf tobacco as raw material which are manufactured to be used for smoking, sucking, chewing or snuffing”.