Tobacco deaths a developing problem:

Tobacco’s killing grounds are shifting to the developing world, as new research from the Harvard School of Public Health shows the number of tobacco-related deaths in developing nations in 2000 roughly equaled those in the industrialized world.

The research, published in the Sept. 13 issue of the medical journal The Lancet, shows that global tobacco deaths were about 4.8 million in 2000, with about 2.4 million each in developing and industrialized nations. The study shows that for men, the shift has already occurred. About 2 million men died in developing nations in 2000 from smoking-related illnesses compared with 1.8 million male deaths in industrialized nations.

“The bottom line is that tobacco at this point in time is no longer [just] a Western problem,” said Harvard School of Public Health Assistant Professor Majid Ezzati, who conducted the research with University of Queensland Professor Alan Lopez.

Though the research paints a bleak picture of 2000’s tobacco-related mortality, it also hints that things are about to get much worse unless anti-smoking campaigns and policies are stepped up globally.

Though deaths due to tobacco are roughly equal in the industrialized and developing worlds, most of the world’s smokers – 930 million out of 1.1 billion – live in developing countries and middle-income nations, including Eastern European nations in the former Soviet bloc.

Ezzati said there haven’t yet been more deaths in developing countries because it takes 20 to 30 years of smoking before large-scale illness and death become visible. Smoking didn’t become popular in those countries until the past quarter century or so, with smoking-related deaths beginning to increase over the past decade.

With those factors at work and without vigorous anti-smoking campaigns, a large increase in tobacco-related deaths is looming.

“The rule of thumb for smoking is that it kills two to three decades after [large numbers of] people start,” Ezzati said.

Preliminary numbers released by the World Health Organization predict global deaths due to smoking-related illnesses will nearly double by 2020, to 9 million, with more than three-quarters of them in the developing world, Ezzati said.

Lung cancer, heart disease

Ezzati and Lopez figured out the number of deaths worldwide due to tobacco by using large epidemiological studies that examined death rates for different diseases among smoking and nonsmoking populations. Because of the lag in health effects of smoking, they also had to find a way to measure the history of smoking, which could be different in each part of the world because people started smoking at different times. They then adjusted those methods for different cultural factors, such as the prevalence of lung disease from smoky cooking fires, to reach final numbers.

Ezzati said that because their methods differed from previous global studies of tobacco-related deaths, the results are not directly comparable. However, he said, the picture that emerges of smoking and tobacco-related illnesses declining in the West and rising rapidly in the rest of the world is consistent with earlier studies.

Their results show that 12 percent of global deaths among adults in 2000 were attributable to smoking-related causes. Smoking accounted for 18 percent of male mortality worldwide and 5 percent of female mortality.

Heart disease and lung disease were the two largest causes of tobacco-related deaths globally. Smoking-related heart disease claimed the largest number of lives, killing 1.69 million people. Lung cancer due to smoking claimed fewer lives, about 850,000, but accounted for a greater proportion of all lung cancer deaths, 71 percent, illustrating that smoking is by far the largest cause of lung cancer globally. Smoking deaths from heart disease accounted for 11 percent of all cardiovascular disease deaths worldwide.

Other major causes of death included throat cancer, chronic lung disease, other cancers, and other respiratory ailments.

Call to action

The study’s figures represent a call to action in middle-income and developing nations, Ezzati said. Anti-smoking campaigns familiar to residents of Western nations are lagging elsewhere, he said. In an anecdote to illustrate the problem, Ezzati described meeting with officials in China to discuss how to reduce lung disease in the Chinese countryside from smoky wood- and coal-burning cooking fires. The meeting rooms, he said, are often filled with cigarette smoke puffed by those attending, sometimes from cigarettes distributed free along with tea at the meeting’s start.

Public health officials working in developing nations have traditionally focused their attention on the problems of infectious disease only, to the exclusion of the growing burden of chronic disease caused by smoking, obesity, and other lifestyle-related illnesses.

Industrialized nations, Ezzati said, had the fortune to be able to deal with many infectious diseases before the arrival of the current era of lifestyle-related illnesses. Today’s developing nations don’t have that luxury.

“The perception seems to be that disease control should be sequential – deal with infectious diseases first and then with chronic diseases,” Ezzati said. “Many developing nations are seeing a double burden [from both types of disease].”

Despite these challenges, Ezzati said there is a chance to develop campaigns and policies that address today’s multiple health threats, including infectious disease and tobacco-related illnesses.

“The positive aspect is that we have an opportunity to think about more comprehensive public health programs, like controlling the same pollutants from cooking fires and cigarettes in many developing countries,” Ezzati said.