Smoking

The cigarette is a very efficient nicotine delivery system

This EUphact solely explores cigarette smoking. Other forms of tobacco use, such as cigar, pipe, water-pipe, hand-rolled tobacco and bidi smoking, as well as smokeless tobacco (such as chewing tobacco), are not included in this overview.

Nicotine has several effects on the brain. An important discovery was made in relation to its addictive potential, namely that nicotine activates reward pathways. The calming effect of nicotine reported by many users is probably associated with a decline in withdrawal effects in addicted individuals rather than the direct effects of nicotine (NIDA, 2006).

Tobacco smoke contains many hazardous chemicals

Smoking leads to three kinds of smoke

• mainstream smoke (MS) is what emerges from the “mouth” or butt of a puffed cigarette;
• sidestream smoke (SS) is what arises from the lit end of a cigarette, mostly between puffs. SS contains a greater amount of carcinogens than MS (IARC, 1986) and
• environmental tobacco smoke (ETS), smoke present in air, consists of exhaled mainstream smoke and sidestream smoke (IOM, 2001).

Smoking prevalence varies widely among EU-27 member states

The most recent data from the WHO-HFA-database (access date: July 2007) are shown in Percentage of daily smokers in the EU-27.

The proportion of those aged 15 years and over who smoke in the EU-27 ranges from 16% in Sweden to 38% in Greece. Despite wide variations in smoking prevalence among member states, the overall average for the 27 EU member states is roughly the same as it was before the EU was enlarged in 2004 and 2007. Consistent large-scale patterns are not apparent, although regional differences on various scales do occur. There are countries with a higher and lower prevalence of smoking in Southern, Northern, Eastern and Western Europe.

Data on the percentage of daily smokers aged 15 years and over in the EU-27 in 2004 are shown in the following maps:

• Adult male daily smokers in the EU-27
• Adult female daily smokers in the EU-27
• Adult daily smokers in the EU-27 (total)

Comparisons are confounded by differences in definitions and data collection

Most countries estimate the percentage of adult smokers on the basis of health interview surveys, which can yield variable data. Variances can, for example, be caused by differences in the way a 'smoker' is defined. For some countries 'smoker' implies a 'daily smoker', for other countries it means a 'regular smoker' and for still other countries it equates to 'all smokers' (which would include occasional smokers). Likewise, for ages defined as 'adult' or '15 years and over' the lower age limit may range from 13 to 20 years and the upper age limit may range from 64 to 84 years. Moreover, population samples are not always representative of the whole country. International comparisons must therefore be made with caution.

Additionally, different international databases may show different data from the same country, as shown in Percentage of adult daily smokers for the databases (WHO-HFA, OECD Health Data and Eurostat). It appears that the data from Eurostat deviate from the data collated in the other two databases. They are probably derived from different national sources or years. Therefore the data from the WHO-HFA have been selected for the presentations.

In general smoking prevalence is higher among men

In Sweden, the smoking prevalence among women is higher than among men.

Typical patterns in both smoking prevalence and trends in smoking prevalence are presented for three selected countries in Percentage of daily smokers in Lithuania, Sweden and the UK.

Smoking prevalence also associated with age and deprivation

For more extensive information on factors affecting smoking prevalence, also see Causes and risk factors

The tobacco epidemic in the EU is evolving

The term 'Tobacco epidemic' refers to a particular global pattern that is visible for tobacco consumption. This started with a peak in smoking behaviour among men, followed by a peak in women, and then related mortality peaks several decades later. The tobacco epidemic has reached different stages in different European countries (see The tobacco epidemic).

In central and eastern European countries there was little awareness of the harmful effects of tobacco smoking until the late 1980s. These countries, as well as some southern European countries are now at stage three of the epidemic, with smoking prevalence among males peaking or just beginning to decline, and smoking prevalence among women still increasing.

Active and passive smoking causes disease

Diseases caused by cigarette smoking are listed in Diseases and adverse health effects caused by smoking. Two diseases that are largely caused by smoking and have the greatest impact on the health of EU citizens in terms of mortality and disability are lung cancer and COPD.

Objective biomarkers for involuntary exposure to tobacco, such as serum cotinine, have been identified and validated. Measurements taken over a number of decades, indicate a significant decline in serum cotinine concentration levels among non-smokers during the 1990s. This decline probably reflects the decrease in exposure on ETS due to anti-smoking interventions, such as restrictions of smoking in the workplace and other public places (Pirkle, 2006).

Smoking plays an important role in early death

Smoking attributable mortality mainly due to CVD and cancer

Cardiovascular disease (CVD) is the largest single cause of death in the EU, accounting for about 40% of male and female deaths. Smoking contributes significantly to mortality via cardiovascular diseases. It has a synergistic effect with other risk factors for cardiovascular disease, such as high cholesterol levels in blood and hypertension (Keil U, et al., 1998).

Cancers of the respiratory tract (lungs, bronchi, and larynx) are responsible for one in 20 deaths in the EU. These cancers are mainly due to smoking (Eurostat, 2002). See also Mortality from lung cancer in the EU-27.

Mortality due to COPD varies from country to country and is influenced by smoking and other factors. According to estimates from vital statistics, smoking is the cause of 62% of all deaths from COPD in the EU-25 (Peto et al., 2005). See also Mortality from lower respiratory disease).

The proportion of deaths attributable to smoking are presented in Percentage of deaths attributabe to smoking, for the main categories of diseases for the year 2000.

Read here about the trends in smoking attributable mortality .

No distinction in health risk between light and regular cigarettes

There is no evidence that so-called light cigarettes (low-nicotine / low-tar) bear reduced health risks in comparison to regular cigarettes. People that switch from regular cigarettes to light cigarettes are likely to inhale the same amount of hazardous chemicals, and thus remain at high risk for developing smoking-related diseases (NCI, 2001).

Tobacco is the leading cause for disease burden in the EU

The term Burden of disease denotes the gap between the current health status and an ideal situation in which everyone lives into old age free of disease and disability. It is usually measured in DALYs. Tobacco is a leading risk factor for disease burden in the developed world, accounting for 12% of the total DALYs (Lopez, 2005).

Ten selected risk factors and ten leading diseases and injuries in the developed world are ranked in Major burden of disease - 10 selected risk factors and 10 leading diseases. This document shows the magnitude of the population attributable fraction that links risk factors with diseases. Tobacco is strongly linked to both COPD and lung cancer, and is known to combine with other risk factors to cause ischaemic heart disease and cerebrovascular disease. The WHO has estimated that in 2000, non-communicable diseases (NCDs) accounted for about 75% of the European burden of disease expressed in DALYs. The most prominent NCDs, such as CVD, cancer and COPD have a common preventable lifestyle-related risk factor, namely tobacco use (WHO, 2002a).

The economic burden of smoking probably exceeds 1% of European GDP

The impact of tobacco morbidity and mortality on society can be expressed in:

• direct costs, associated with health care (hospitalisation, ambulatory care, prescription drugs, home health care and nursing home services) for smoking related diseases among smokers and second-hand smoke (SHS) victims; and
• indirect costs, associated with the loss of human capital due to tobacco attributable premature deaths, productivity losses, unpaid income taxes and contributions to social security from smokers, patient-SHS victims and carers who would otherwise be in paid employment (informal care).

The current existing estimates of the total smoking-attributable costs for the two leading (groups) of smoking related diseases in Europe: COPD and CVD, amount to between €105.83 billion and €130.31 billion for the year 2000, or about 1% of the region’s GDP. The indirect costs of smoking account for two-thirds of this amount. This is a very conservative estimate, considering the fact that only two major diseases have been included, and even for these two diseases not all the costs have been taken into account (e.g. the costs of informal care, the costs linked to the treatment of reproductive problems, the costs related to SHS and budgetary costs related to social services). A more comprehensive estimate of net social costs has been recorded for Australia and ranges between 2.1% and 3.4% of their GDP (ASPECT, 2004; Collins & Lapsley, 2002).

Nicotine addiction is better understood now

The underlying cause of regular, daily smoking is nicotine addiction. Tobacco smoke contains nicotine, which creates a strong physical and psychological chemical dependence or addiction. Besides nicotine, tobacco smoke also contains thousands of other chemicals, such as tar, carbon monoxide, acetaldehyde and nitrosamines. The cigarette is a very efficient nicotine delivery system. When inhaling cigarette smoke, a smoker takes in 1 to 2 mg of nicotine per cigarette. Nicotine levels peak in the blood and reach the brain rapidly, triggering several reactions, such as increases in blood pressure, heart rate and respiration rate. In the brain, nicotine stimulates reward pathways that regulate feelings of pleasure.

Dependence is strongest when tobacco smoke is inhaled into the lungs and increases with the quantity and speed of nicotine absorption. An improved understanding of addiction and of nicotine as an addictive drug has been instrumental in developing medications and behavioural treatments for tobacco addiction (NIDA, 2006).

Sex, age, socio-economic status as determinants of smoking

Sex

The prevalence of smoking is higher among men than among women. Although more and more women are taking up smoking, this picture is not likely to reverse. Female smoking rates reached a plateau at lower levels than male rates in some countries, and have started decreasing in some countries. The Global Youth Tobacco Survey, however, showed that the difference in smoking rates between boys and girls is narrower than expected, especially in the Americas and in Europe. In the Americas, more girls smoke than boys, and there is only a small difference between the sexes in Europe, with 19.9% of boys smoking, and 15.7% of girls. The unexpected increase in cigarette consumption among girls will have important implications for the global burden of chronic diseases and should be considered in future mortality projections (Warren et al., 2006).

Also see The tobacco epidemic.

Age

The prevalence of smoking is generally higher among young people than among the elderly. The Global Youth Tobacco Survey also revealed that Europe has the highest incidence of youth smoking in the world. Nearly 18% of Europeans aged 13 to 15 are smokers, more than twice the global average of 8.9% (Warren et al., 2006).

Socio-economic inequalities in smoking

The tobacco epidemic can be divided into four socio-economic related stages (Cavelaars et al., 2000). These are described in: Socio-economic aspects of the tobacco epidemic.

In most countries smoking is more prevalent among the lower educated, whereby education can be viewed as an indicator for socio-economic status.

A general north-south pattern can be observed, with strong social gradients in northern European countries and weaker or reversed social gradients in southern European countries (Eurothine, 2007). Social gradients in smoking prevalence are stronger for younger men and women than for the older generations. These stronger social gradients of smoking prevalence are likely to translate into stronger gradients in smoking attributable morbidity and mortality in the future (Cavelaars et al., 2000).

See also: EUphocus Health inequalities.

Collective approaches to reduce smoking

The main approaches to reduce tobacco smoking are (WHO-HEN, 2003):

• price increases through higher taxes;
• advertising and promotional bans;
• smoking restrictions;
• consumer education campaigns; and
• smoking cessation therapies.

Collective approaches to reduce smoking require particular attention. They are described in more detail in the EUphact Smoking policies.

Individual approaches to smoking cessation

An individual approach to smoking cessation includes pharmacotherapies and behavioural therapies. They are most effective when combined with collective interventions.

Pharmacotherapy increases the probability of long-term cessation

Only 3% of smokers manage to quit smoking using will power alone (ASH, 2006). Success depends to a great extent on motivation, but a combination of pharmacotherapy and behavioural therapy probably yields the best results.

Nicotine replacement therapy

Nicotine replacement therapy (NRT) in the form of patches, chewing gum, lozenges, inhalers and nasal sprays helps relieve the withdrawal symptoms that prevent many smokers from quitting. This therapy contains nicotine, but does not contain the other harmful substances found in cigarettes, such as tar, carbon monoxide, nitrosamines.

Non-nicotine pharmacotherapy

Non-nicotine pharmacotherapy includes different types of drugs. Two of the most promising are bupropion and varenicline. They are both prescription drugs approved by the national authorities of some countries to help patients stop smoking. Bupropion is an anti-depressant drug, that reduces withdrawal symptoms and lessens the urge to smoke. Varenicline, very recently approved both in Europe and the USA, is a partial nicotine agonist that prevents nicotine-withdrawal symptoms, and eliminates the feeling of pleasure that people experience when smoking.

Behavioural treatment can improve the quit rate

Certain moods, times of day, or activities can act as strong triggers for craving a cigarette. Pharmacotherapy is not a cure for these smoking triggers. Furthermore, the motivation to quit smoking determines to a large extent the success rate of smoking cessation. Some studies have found that the integration of behavioural therapy can increase the cessation rate by another 50-100% (Fiore et al., 2000). Psychosocial interventions can be usefully employed at every stage of the tobacco addiction treatment, not only during the first stage(Foulds et al., 2006). There are a wide range of available psychosocial treatment options, including counselling via the internet and the telephone, as well as individual and group counselling.

Mortality patterns reflect smoking behaviour in the past

Mortality patterns today are indicative of smoking behaviour two to three decades ago. The tobacco epidemic is at different stages in different EU countries: Western European men began smoking early in the 20th century, while women took up smoking in the second half of the 20th century. Smoking prevalence among men in Western Europe started to decline from the 1950s onwards and among women from the mid-1970s onwards. This is reflected in today's mortality patterns that are declining for both sexes. In Central and Eastern Europe people's awareness levels of the harmful effects of smoking were low until near the end of the 1980s. The prevalence of smoking among men in Central and Eastern European countries is either peaking or starting to decline now, while among women it is still increasing (ASPECT, 2004).

Mortality among women is still rising

The overall trends in mortality for smoking-attributable deaths during the second half of 20th century are illustrated for the EU-25 in Trends in smoking attributable mortality. The overall proportion of smoking attributable deaths among women is still rising, while male mortality already reached its peak in the 1980s.

Infant mortality

Life expectancy

Healthy life expectancy

Children's Health and the Environment

Health Inequalities

Lung cancer

Smoking policies

COPD

Diabetes prevention and care

Blood pressure

WHO-HFA-DB WHO Health for all database

OECD Health Data

Eurostat Statistical database of the European Union

Peto et al. Mortality from smoking in developed countries

Health-EU Portal, tobacco The Public Health Portal of the European Union

Bold CHILD Child health Indicators of Life and Development

FCTC WHO Framework Convention on Tobacco Control

ENSP European Network for Smoking Prevention

IMCA Indicators for Monitoring Chronical Obstructive Pulmonary Disease and asthma in the EU

PANACEA Physical Activity, Nutrition, Alcohol, Cessation of Smoking, Eating out of home And obesity

ENHIS European Environment and Health Information System

EUROCISS European Cardiovascular Indicators Surveillance Set

ASPECT consortium report: Tobacco or health in the European Union: past, present and future

Percentage of adult daily smokers in the EU-27

Percentage of adult daily smokers, comparison of data from three different databases

Percentage of deaths attributable to smoking, in a number of countries, in 2000

Percentage of all deaths attributable to smoking, in a number of countries, in 2000

Trends in smoking attributable mortality in the EU-25 (1965-2000)

Percentage adult daily smokers, total in the EU-27, in 2004

Percentage adult daily smokers, men in the EU-27, in 2004

Percentage adult daily smokers, women in the EU-27, in 2004