last updated february 2011 demographics and health effects revised 05/06

Last updated February 2011

Demographics andHealth Effects

Revised 05/06


Demographics and Health Effects Section

Revised 05/06

Chair Ann Malarcher Centers for Disease Control and Prevention, Atlanta, USA

Peter Anderson Indept. Consultant in Public Health, Spain

Mary-Jane Ashley University of Toronto, Canada

Shanta R Dube Centers for Disease Control and Prevention, Atlanta, USA

Linda Pederson Centers for Disease Control and Prevention, Atlanta, USA

Jonathan Samet Johns Hopkins University, School of Hygiene and Public Health, Baltimore, USA

Michael Thun American Cancer Society, Atlanta, USA


Health and Economic Costs of Tobacco Use


Estimates are based on data and information from the World Health Organization* Childhood and maternal under nutrition includes: vitamin A Deficiency, zinc, iron; under weight 1 Years of life lost

Global burden of disease and injury attributableto selected risk factors, 2000 (Total in thousands)

Risk Factor Deaths (thousands)

% of total deaths

YLLs1 (thousands)

As % of total YLLs1

Childhood and maternal under nutrition*

6,156 11.0 205,372 22.4

Tobacco 4,907 8.8 45,622 5.0

Blood Pressure 7,141 12.5 55,548 6.0

Physical Inactivity 1,922 3.4 15,841 1.7

Occupation 784 1.4 9,975 1.1

Unsafe sex 2,886 5.2 76,970 8.4

Alcohol 1,800 3.2 32,697 3.6

Unsafe water, sanitation and hygiene

1,730 3.1 49,232 5.4

Illicit drugs 204 .4 4,819 .5

Urban air pollution 799 1.4 6,404 .7


AFRO African Region

AMERO Region of the Americas

EMRO Eastern Mediterranean Region

EURO European Region

SEARO South-East Asia Region

WPRO Western Pacific Region


Projected global burden of lung cancer in 2030

Mathers, C., & Loncar, D. (2005). Updated projections of global mortality and burden of disease, 2002-2030: data sources, methods and results. World Health Organization

Region Total deaths(thousands)

Male Female

AFRO 39 31 8

AMRO 288 185 103

EMRO 76 61 16

EURO 362 226 137

SEARO 467 364 103

WPRO 984 656 328

WORLD 2,216 1,522 694


Projected global burden of ischemic heart disease in 2030


Region Total deaths (thousands)

Male Female

AFRO 610 312 298

AMRO 1,321 638 683

EMRO 1,026 539 487

EURO 2,223 982 1,241

SEARO 3,187 1,627 1,559

WPRO 1,369 604 765

WORLD 9,737 4,702 5,034


Projected global burden of COPD in 2030



Male Female

AFRO 243 159 84

AMRO 379 216 163

EMRO 236 131 105

EURO 354 165 189

SEARO 1,537 886 651

WPRO 3,148 1,425 1,723

WORLD 5,896 2,981 2,915


Projected global burden of cerebrovascular disease in 2030



Male Female

AFRO 672 269 402

AMRO 659 277 382

EMRO 451 208 243

EURO 1,400 510 890

SEARO 1,816 807 1,009

WPRO 2,679 1,189 1,491

WORLD 7,677 3,260 4,417


Burden of disease and injury attributable to tobacco use, 2000

Estimates are based on data and information from the World Health Organization1 Years of life lost

Region Deaths(thousands)

As % of total deaths

YLLs1 (thousands)

As % of total YLLs1

AFRO 160 1.5 2,002 .7

AMRO 873 14.9 6,548 9.7

EMRO 186 4.6 2,279 2.6

EURO 1,605 16.7 14,839 17.7

SEARO 1,110 7.8 12,264 4.6

WPRO 975 8.4 7,692 5.5

WORLD 4,907 8.8 45,622 5.0


*Age-adjusted to the 2000 US standard population. US Mortality Public Use Data Tapes 1960-2003, US Mortality Volumes 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006.

0

20

40

60

80

10019

30

1935

1940

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

Lung

Colon & rectum

Stomach

Rate Per 100,000

Prostate

Pancreas

LiverLeukemia

Cancer Death Rates*, for Men, US,1930-2003


0

20

40

60

80

10019

30

1935

1940

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

Lung

Colon & rectum

Uterus

Stomach

Breast

Ovary

Pancreas

Cancer Death Rates*, for Women, US,1930-2003

*Age-adjusted to the 2000 US standard population. US Mortality Public Use Data Tapes 1960-2003, US Mortality Volumes 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006.

Rate Per 100,000


Smoking-Attributable Mortality Fractions Among Males in the United States, 2001

0

20

40

60

80

100 35-64 yrs

65+ yrs

Infants

CDC, Adult SAMMEC, http://apps.nccd.cdc.gov/sammec/

Per

cent

age


Smoking-Attributable Mortality Fractions Among Females in the United States, 2001

0

20

40

60

80

100 35-64 yrs65+ yrs Infants

CDC, Adult SAMMEC, http://apps.nccd.cdc.gov/sammec/

Per

cent

age


Ischmeic Heart Disease; 86,801

Other Diagnosis; 35,502

Other Cancers; 34,693

Secon Hand Smoke Deaths; 38,112

Lung Cancer; 123,836 Respiratory Diseases; 101,454

Stroke (Cerbovascular Disease); 17,436

CDC. Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses – United States, 1997-2001. MMWR 2005;54(25): 625-628

Nearly 440,000 Average Annual Deaths Attributable to Cigarette Smoking – United States, 1997-2001

Ischemic Heart Disease; 86,801


National Center for Health Statistics, Deaths: Final Deaths 2003. National Vital Statistics Report, 2006; 54(13); Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses- United States, 1997-2001; MMWR. 2005:54(25):625-628.

14 2145

18 29 31

438

04080

120160200240280320360400440

Num

ber

of d

eath

(th

ousa

nds)

Annual Deaths from Smoking Compared with Selected Other Causes in the United States


One out of two lifelong

adult smokers will die

from a smoking related

disease.

CDC. Projected smoking-related deaths among youth – United States. MMWR 1996;45(44):971-974


Smoking and Health Among Adolescents

• Rapid addiction to nicotine from early smoking• More likely to use other drugs (alcohol, marijuana, &

cocaine) • More likely to be involved in other risky behaviors• Poorer overall health• Increased resting heart rates

USDHHS. Preventing Tobacco Use Among Young People: A Report of the Surgeon General, 1994; Arday, DR, et al. Cigarette smoking and self-reported health problems among US high school seniors, 1982-1989Am J of Health Promotion 1995;10(2):111-116.


Smoking and Health Among Adolescents

Increased effects on the respiratory system• Increased wheezing, gasping and shortness of

breath• Increased coughing and phlegm production• Decreased physical performance• Decreased endurance• Reduced lung function• Slowed growth of lung function

USDHHS. Preventing Tobacco Use Among Young People: A Report of the Surgeon General, 1994; Arday et al. Cigarette smoking and self-reported health problems among US high school seniors, 1982-1989. Am J Health Promot 1995;10: 111-116.


Effects of Smoking and Pregnancy/Reproduction

• Reduced Fertility• Reduced risk for preclampsia• Fetal growth restriction • Increased risk of premature rupture of the membranes,

placenta previa, & placental abruption • Increased risk of preterm delivery & shortened gestation

USDHHS. The Health Consequences of Smoking: A Report of the Surgeon General, 2004.


• Increased risk of low birth weight• Increased risk of perinatal mortality (stillbirth & neonatal

deaths)• Increased risk of reduction of lung function in infants• Increased risk of sudden infant death syndrome (SIDS)

USDHHS. The Health Consequences of Smoking: A Report of the Surgeon General, 2004.

Effects of Smoking and Pregnancy/Reproduction


Health Effects of Secondhand Smoke


Contents of Secondhand Smoke (SHS)

• Cigarette smoke contains more than 7000 chemical compounds

• Sixty nine chemicals in tobacco smoke are known or probable carcinogens

• SHS is a known human carcinogen

USDHHS. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General, 2006.


“An hour a day in a room with smoke is nearly a hundred times more likely to cause lung cancer in a non-smoker than 20 years spent in a building containing asbestos.”

-Sir Richard Doll, 1985


Health Effects of Secondhand Smoke - Adults

• SHS exposure causes lung cancer among lifetime nonsmokers

• SHS exposure associated with living with a smoker increases risk of lung cancer by 20%-30%.

• SHS exposure causes coronary heart disease morbidity and mortality

• SHS exposure increases risk of heart disease by 25%-30%

• SHS exposure causes increased respiratory symptoms of odor annoyance & nasal irritation



Health Effects of Secondhand Smoke -Children

• SHS exposure causes sudden infant death syndrome (SIDS)

• Maternal exposure to SHS during pregnancy causes a small reduction in birth weight

• SHS exposure after birth causes a lower level of lung function

• SHS exposure from parental smoking causes lower respiratory illness in infants and children



• SHS from parental smoking causes cough, phlegm, wheeze and breathlessness in school age children

• SHS from parental smoking causes exacerbations of asthma

• SHS exposure from parental smoking causes the onset of wheeze illness in early childhood

• SHS exposure from parental smoking causes middle ear disease (acute and recurrent otitis media, chronic middle ear effusion)


Health Effects of Secondhand Smoke -Children


Approximately, 5 million people will die from tobacco related illness this year. By 2030, 10 million people will

die each year.

World Health Organization. The Tobacco Atlas (2002). http://www.who.int/tobacco/en/atlas11.pdf Ezzati & Lopez. Estimates of Global Mortality Attributable to Smoking in 2000. Lancet 2003; 362: 847-852.


Benefits of Cessation


Benefits of Cessation Overall

• Former smokers live longer compared with continuing smokers

• Smoking cessation reduces risk of premature death• Risk of death decrease shortly after quitting• Smoking cessation benefits almost every part of the body

USDHHS. The Health Benefits of Smoking Cessation: A Report of the Surgeon General, 1990


Smoking Cessation and Lungs

• Lung function starts to improve 2-3 months after quitting• Smoking cessation reduces risk of lung cancer, 10 years

after quitting, the risk of lung cancer decreases to 30- 50% that of a continuing smoker



Smoking Cessation and the Respiratory System

• Risk of death from Chronic Obstructive Pulmonary Disease is decreased after quitting

• Risk of upper and lower respiratory illness such as colds, flu, bronchitis and pneumonia is lowered

• Coughing, sinus congestion, fatigue and shortness of breath decrease 2-3 months after quitting

• Smoking cessation lowers risk of larynx cancer



Smoking Cessation and the Heart

• Smoking cessation reduces the excess risk of dying from abdominal aortic aneurysm by 50% among former smokers

• Risk of coronary heart disease decreases by half 1-2 years after quitting

• After 15 years of quitting, coronary heart disease risk is nearly that of a non-smoker

• Among persons diagnosed with cardiovascular heart disease, smoking cessation reduces risk of recurrent infarction and cardiovascular death

• After quitting peripheral artery disease decreases



Smoking Cessation and Other Parts of the Body

• Stroke risk is reduced to that of a never smoker after 5 to 15 years of cessation

• Risk of mouth, throat, and esophagus cancers are halved five years after quitting

• Bladder cancer risk is halved a few years after quitting• Smoking cessation lowers the risk of kidney, stomach,

pancreatic and cervical cancer• Smoking cessation lowers risk of peptic ulcers



Smoking Cessation and Pregnancy

• Quitting smoking before or early during pregnancy lowers risk of miscarriage, low birth weight of baby and SIDS

• Although abstinence early in pregnancy will produce the greatest benefits to the fetus and expectant mother, quitting at any point in pregnancy can yield benefits



Summary: Health Benefits of Smoking Cessation

• Smoking cessation has major and immediate health benefits for men and women of all ages

• Benefits apply to persons with and without smoking-related diseases

• Former smokers live longer than continuing smokers• Smoking cessation decreases the risk of lung and other

cancers, heart attack, stroke, and chronic lung disease• Smoking cessation improves reproductive outcomes



Tobacco Dependence


"In a sense, the tobacco industry may be thought of as being a specialized, highly ritualized, and stylized segment of the pharmaceutical industry. Tobacco

products uniquely contain and deliver nicotine, a potent drug with a variety of physiological effects."

-1972 Claude Teague memo "RJR Confidential Research Planning Memorandum on the Nature of the

Tobacco Business and the Crucial Role of Nicotine Therein”


Frequency of Cigarette Use, 2004

SAMHSA (2005), Results from the 2004 National Survey on Drug Use & Health

02468

1012141618

12 17 24 30-34 40-49 50-65

Age

Avg CPD

Per

cent

age


Tobacco Dependence in the United States, 2004

• 35.5 million Americans 12 years or older met the criteria for nicotine dependence in the past month based on their cigarette use

• 1.1 million youth 12 to 17 years old are nicotine dependent cigarette smokers

• The rate of dependence is higher for those who start smoking at an earlier age than for those who initiate cigarette use later in life



Nicotine Dependence among Past Month Smokers, by age, 2004



Relapse Rate Over Time

100

90

80

70

60

50

40

30

20

10

0

Heroin

Smoking

Alcohol

0 1 2 3 4 5 6 7 8 9 10 11 12

Time (Months)2 Weeks

Ab

stai

ner

s (%

)

USDHHS. The Health and Consequences of Tobacco: Nicotine Addiction. A Report of the Surgeon General, 1988.


80,000 to 100,000 young people around the world become addicted to tobacco, everyday.

World Bank, Curbing the Epidemic: Governments and the Economics of Tobacco Control (Washington: World Bank, 1999).


Effective Treatment Interventions


Effective Treatment Interventions

• Brief advice to quit from doctors, nurses and other healthcare providers

• Group counseling• Individual counseling• Telephone counseling• Pharmacotherapy

Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline.Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.


Identification and Assessment of Tobacco Use

• Assisting the patient in quitting (5A’s)– Ask – Systematically identify all tobacco users at

every visit – Advise – Strongly urge all tobacco users to quit– Assess – Determine willingness to make a quit

attempt– Assist – Aid the patient in quitting– Arrange – Schedule follow-up contact



Effective counseling treatment for tobacco use and dependence

• Practical counseling (problem solving/skills training)• Intra-treatment social support



Elements of counseling

• Practical Counseling – Recognize danger situations– Develop coping skills– Provide basic information

• Supportive Counseling – Encourage the patient in the quit attempt– Communicate caring and concern– Encourage the patient to talk about the quitting

process



Effective pharmacotherapy for smoking cessation

• Pharmacotherapy that reliably increase long term smoking abstinence rates

• Bupropion • Nicotine gum, inhaler, nasal spray, lozenge and

patch• Varenicline• Clonidine and Nortriptyline can be used if other

pharmacotherapy is not effective


Motivational intervention for those unwilling to quit consist of the 5 R’s

• Relevance – Encourage patient to identify why quitting is relevant

• Risks – Ask patient to identify potential negative consequences of tobacco use

• Rewards – Ask patient to identify potential benefits of quitting

• Roadblocks – Ask patient to identify barriers to quitting• Repetition – Repeat motivational intervention every time

unmotivated patient enters a clinical setting



• Increase the unit price for tobacco products• Mass media education campaigns combined with other

interventions to inform and motivate tobacco users to quit• Provider reminder systems that identify patients who use

tobacco products and prompt providers to discuss cessation with their client or advise client to quit at every encounter

Task Force on Community Preventative Services. Zaza S, Briss PA, Harris, KW (eds). The Guide to CommunityPreventative Services. Oxford University Press. New York, New York, 2005.

Recommendations for increasing tobacco cessation


• Provider reminder plus provider education, with or without client education

• Reduction of out-of pocket costs for effective cessation therapies

• Multi-component interventions that include client telephone support

Task Force on Community Preventative Services. Zaza S, Briss PA, Harris, KW (eds). The Guide to CommunityPreventative Services. Oxford University Press. New York, New York, 2005.



• Standardization of care for routine, effective treatment of tobacco use needs

• Continuous screening of tobacco use among those who enter the health care system

• Availability of effective intensive treatments that includes counseling and pharmacotherapy




• Treatment that emphasizes problem-solving and within-treatment social support

• Extended or augmented psychosocial interventions beyond minimal advice to quit for pregnant smokers

• Institutionalize system changes that are essential to ensure that clinical interventions occur

last updated february 2011 demographics and health effects revised 05/06

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