Tobacco

Overview

The tobacco epidemic is one of the biggest public health threats the world has ever faced, killing more than 8 million people a year, including around 1.2 million deaths from exposure to second-hand smoke (1).

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.

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.

Key measures to reduce the demand for tobacco

Second-hand smoke

Second-hand tobacco smoke is the smoke emitted from the burning end of a cigarette or from other smoked tobacco products (such as bidis and water-pipes) and the smoke exhaled by the smoker. More than 4000 chemicals have been identified in tobacco smoke and there is no safe level of exposure to second-hand tobacco smoke.

Based on the scientific evidence, the Conference of the Parties to the WHO Framework Convention of Tobacco Control (WHO FCTC) has concluded that 100% smoke-free environments are the only proven way to adequately protect the health of people from the harmful effects of second-hand tobacco smoke. 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

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.  

Tobacco advertising

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 advertising on television, radio, print publications, billboards and social media platforms.
• Indirect forms include brand sharing, brand stretching, free distribution, price discounts, point of sale product displays, sponsorships and promotional activities masquerading as corporate social responsibility programmes.  

Taxes

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.

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.

Quitting tobacco

When tobacco users become aware of the dangers of tobacco, most want to quit. However, nicotine contained on tobacco products is highly addictive and without cessation support only 4% of users who attempt to quit tobacco use will succeed. Professional support and proven cessation medications can more than double a tobacco user's chance of successful quitting.  

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. HTPs produce aerosols containing nicotine and toxic chemicals upon heating of the tobacco, or activation of a device containing the tobacco. 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 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 (2). 

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 4 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 (4, 5).

WHO response

The scale of the human and economic tragedy that tobacco imposes is shocking, but it’s also preventable. The tobacco industry 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.

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.

The 6 MPOWER measures are:

• Monitor tobacco use and prevention policies
• Protect people from tobacco use
• Offer help to quit tobacco use
• Warn about the dangers of tobacco
• Enforce 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. 

References

(1)  Global Burden of Disease [database].Washington, DC: Institute of Health Metrics; 2019. IHME,accessed 17 July 2021

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

(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”