Elsevier

The Lancet

Volume 362, Issue 9387, 13 September 2003, Pages 847-852
The Lancet

Articles
Estimates of global mortality attributable to smoking in 2000

https://doi.org/10.1016/S0140-6736(03)14338-3Get rights and content

Summary

Background

Smoking is a risk factor for several diseases and has been increasing in many developing countries. Our aim was to estimate global and regional mortality in 2000 caused by smoking, including an analysis of uncertainty.

Methods

Following the methods of Peto and colleagues, we used lung-cancer mortality as an indirect marker for accumulated smoking risk. Never-smoker lung-cancer mortality was estimated based on the household use of coal with poor ventilation. Relative risks were taken from the American Cancer Society Cancer Prevention Study, phase II, and the retrospective proportional mortality analysis of Liu and colleagues in China. Relative risks were corrected for confounding and extrapolation to other regions.

Results

We estimated that in 2000, 4·83 (uncertainty range 3·94–5·93) million premature deaths in the world were attributable to smoking; 2·41 (1·80–3·15) million in developing countries and 2·43 (2·13–2·78) million in industrialised countries. 3·84 million of these deaths were in men. The leading causes of death from smoking were cardiovascular diseases (1·69 million deaths), chronic obstructive pulmonary disease (0·97 million deaths), and lung cancer (0·85 million deaths).

Interpretation

Smoking was an important cause of global mortality in 2000. In view of the expected demographic and epidemiological transitions and current smoking patterns in the developing world, the health loss due to smoking will grow even larger unless effective interventions and policies that reduce smoking among men and prevent increases among women in developing countries are implemented.

Introduction

Smoking is a risk factor for mortality from several medical causes.1 The hazards of smoking depend on factors such as the age at which smoking began, number of cigarettes smoked per day, cigarette characteristics, such as tar and nicotine content or filter type, and smoking behaviour, such as degree of inhalation.2 Many of these factors vary over time and across generations because of changes in the socioeconomic determinants of smoking, such as income, and tobacco control efforts, including tobacco trade and advertising laws, and prices (including taxes). Therefore, current smoking prevalence or tobacco consumption alone would be insufficient indicators of the accumulated risk from smoking, even if detailed data were available in all countries.

To strengthen the scientific evidence for national and global tobacco control efforts, a consistent method is needed to estimate the health effects of smoking across different populations and different points in time. In this paper, we extend the indirect Peto-Lopez method3 for estimation of mortality attributable to smoking to developing countries, with emphasis on factors that affect lung-cancer mortality among non-smokers. The emphasis on developing countries is particularly important because of shifting global smoking patterns, with an estimated 930 million of the world's 1·1 billion smokers living in low-income and middle-income countries.4 Despite recent improvements in the data required for the method, substantial uncertainty still remains about the levels of smoking-attributable mortality, especially in developing countries. We addressed this issue by providing a quantitative analysis of uncertainty.

Section snippets

Smoking impact ratio

Following the methods of Peto and colleagues,3 we used lung-cancer mortality as an indirect indicator of the accumulated hazards of smoking. Background-adjusted smoking impact ratio (SIR) was defined as population lung-cancer mortality in excess of never-smokers, relative to excess lung-cancer mortality for a known reference group of smokers, adjusted to account for differences in never-smoker lung-cancer mortality rates across populations.5 Conceptually, by using excess lung-cancer mortality

Results

Table 1 shows the estimated number of smoking-attributable deaths, divided into causes and age groups in table 2, and into 14 epidemiological subregions of the world as defined in the GBD project6, 7 in table 3. The 4·83 (uncertainly range 3·94–5·93) million deaths attributable to smoking were 12% of the estimated total global adult (those older than 30 years) mortality in 2000. 18% and 5% of total adult male and female mortality, respectively, were attributable to smoking. Smoking killed 3·0

Discussion

By using lung cancer mortality as an indirect indicator of the accumulated hazards of smoking, we estimated that 4·83 (uncertainty range 3·94–5·93) million premature deaths in the world were attributable to smoking in the year 2000. Numbers of deaths were almost equal in developing and industrialised regions of the world, and were greater in men than in women, especially in developing countries.

The reliability of mortality estimates based on the indirect SIR method has been confirmed against

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