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Chapter seven
Key trends for 2000 and beyond
Dr Alan Lopez: Tobacco is unique in its killing ability
r Alan Lopez of the WHO argues that by 2020 tobacco will be the
main cause of death in the world. Through his research Lopez has
amassed much evidence of the unique nature of the public health
hazard resulting from tobacco use. But getting the message across
to decision-makers and individual smokers themselves is a another
question.
...the real impact of tobacco needs to be understood better.
Dr Lopez is an epidemiologist and programme manager for the World
Health Organization. He is also responsible for the WHO programme
on substance abuse, which comprises all activities dealing with
addictive substance addiction involving tobacco, alcohol and illicit
drugs.
Dr Lopez says that the real impact of tobacco needs to be understood
better. He has recently been studying morbidity, disability and
death in different populations throughout the world, and together
with Richard Peto is preparing the second edition on Mortality from
Smoking in Developed Countries. The first edition, now sold out,
covered the period 1950-2000.
Alarming trend for decades
The Peto-Lopez study reaffirmed that tobacco is a killer. And
it stays a killer, according to recent study findings by Lopez
and Dr. Christopher J.L. Murray, Harvard professor of international health
economics. The conclusions of a nearly five-year study by the
Harvard School of Public Health, World Health Organization and
the World Bank entitled the Global Burden of Disease show that
noncommunicable diseases and accidents are rapidly replacing diseases
and malnutrition as the primary cause of death the world over.
The study estimates that by 2020 over eight million will die annually
from smoking-related illnesses, compared to the current figure
of three million. Murray and Lopez noted that the extraordinary
epidemic of tobacco-related mortality and disability emerges as
the most alarming trend over the next three decade.
"We are going from three million deaths to 8-9 million deaths
in couple of decades. We can see changes in how these deaths occur",
says Lopez. "Other causes of death are declining: we are succeeding
in bringing down malaria, tuberculosis and HIV. By 2020 tobacco
will be the single largest cause of death, and the single largest
public health problem in the world. It will cause more deaths
than measles, complications of childbirth and HIV combined. This
needs to be better understood."
Figures, accuracy and projection
Lopez argues that major public health risks has to be quantified
by the scientific community in order to get independent, objective
information. But how accurate are the projections of tobacco-related
deaths worldwide?
"There has been the evaluation by tobacco industry, which of course
is very negative and critical. Richard Peto and I claimed in our
book that in the rich countries of the world--Europe, North America,
Australia, and so on -tobacco kills about two million people a
year. The tobacco industry claims that this is exaggerated, but
they still admit that tobacco is killing a large number of people.
It might even be killing more than two million a year.
"On the other hand, the book has been widely received and used
by the advocates of the tobacco control community. This is what
the book was for--it is not a detailed scientific book in the
sense one would expect. All the science and methods were published
earlier in The Lancet. This book was an attempt to take that science
and translate it into actual tables, numbers, figures so that
people in Finland, Lithuania or Spain could use it and show policy
makers the impact count--the past impact and more importantly
the projected impact of tobacco if we don't do anything about
it.
"Richard Peto and I are now beginning to work with the second
edition. It will use the 1995 data as an index, as our first edition
used the 1990 data. By the time we get to work on this, we plan
to look at the 1995 data. That would give us even more accurate
projections of the future."
Numbers are relatively consistent
"More recently I have been involved with the World Bank and Harvard
University on the much larger study called The Global Burden of
Disease. This attempts to quantify the mortality and morbidity
rate in over a hundred diseases and injuries and the risk factors,
including tobacco. Professor Murray and I made projections of
tobacco deaths up until 2020 by region, age, sex and cause--which
is a very detailed compilation. The instruments are similar to
the ones Professor Peto and I used. Earlier work suggested that
tobacco will kill about ten million people a year in 2020«s or
early 2030«s. Professor Murray and I estimate that in 2020 the
number will already be about 8-81/2 million, so these numbers
are relatively consistent."
Lung cancer and baseline data
"The method Professor Peto and I developed is really related to
ignoring what classical epidemiology has done. Classical epidemiology
takes prevalence--let«s say smoking in Finland--and relates it
to a set of relative risks. Peto and I said that the whole history
of countries smoking epidemic is in their lung cancer rate. If
you subtract a little bit of the lung cancer rate due to background
factors that the smokers and non-smokers are likely to experience,
anything left is likely to be due to smoking. We then scaled the
set of relative risks like heart diseases, chronic lung diseases
and all the cancers and we look an the country's lung cancer rate.
As a result of looking at it, we can make a decision of the proportion
of other diseases that should also be attributed to tobacco. If
the male lung cancer rate is high, then it is likely that the
other diseases caused by tobacco are also high. Baseline data
is very important to these projections. In many countries lung
cancer rates are coming down. This means that the tobacco deaths
will also be falling."
Trouble shooting with the World Bank
Future projections also give the tobacco control community a pretty
clear picture of the future trouble spots. Tobacco-related diseases
develop slowly, and the statistical projections are about 30 years
behind the real situation. Scientists such as Lopez work hard
to ensure the projected future never arrives. They also urge decision-makers
to rely more on this evidence-based health policy, as they call
it.
WHO has in recent years collaborated with the World Bank and the
European Union.
Lopez says that the big issue WHO would like to see happen in
Europe is a ban on advertising and promotion of tobacco products
within the European Union.
Working with the World Bank has been fruitful because the tobacco
agenda goes far beyond health issues.
"Questions related to economic aspects and development are completely
outside the WHO mandate. We need to forge partnerships with major
international organizations. Our collaboration with the World
Bank on economic aspects of tobacco has been successful. The World
Bank now has very restrictive policies on loans for tobacco production,
and is not only refusing to lend money for tobacco products but
also becoming more actively involved with WHO in research and
information. Countries need to be convinced that tobacco actually
is far more greater cause of economic loss than it is of economic
gain."
Adult mortality, tobacco and eastern Europe
WHO focuses on tobacco issues in Central and Eastern Europe and
not only in EU Europe. Lopez describes the situation in these
large areas of the continent as "alarming".
"Take Hungary. You have levels of lung cancer in middle-aged men
which exceed the highest level ever recorded in the United Kingdom--which
had by far the worst lung cancer epidemic from tobacco. And the
lung cancer rates in Hungary are still on the rise. There are
many other countries in Central and Eastern Europe, where the
situation is perhaps not as alarming, but nevertheless very worrying.
"Tobacco consumption is showing no sign of declining. On top of
this we have a very active effort by tobacco industry to promote
tobacco goods under the guise of freedom of lifestyle. The new
political environment appears tremendously explosive and potentially
dangerous in terms of public health care."
Lopez says that the levels of adult mortality among men in Central
and Eastern Europe are unlikely to decline during the next couple
of decades.
"Adult mortality may even rise because of the massive tobacco
epidemic that is already present in these countries. Tobacco consumption
levels are very high. This is probably the region in the world,
along with China, about which WHO is the most concerned. Yes, tobacco is
public health enemy number one."
"...if you start smoking in your teenage years and continue to
do so systemically, you will have about a 50 per cent chance of
being killed by tobacco."
Dr. Lopez is often asked whether tobacco is really more of a health
risk than illicit drugs from WHO`s point of view. Lopez has both
a short answer and a longer explanation.
"Yes, tobacco is a far greater risk than drugs or alcohol. Unquestionably
alcohol and drugs cause a lot of social disruption, whereas tobacco
simply kills you. This is the issue society has to deal with:
can we afford to tolerate the degrees of sickness and premature
deaths that arise from an addiction that is an extremely effective
killer? People need to understand that tobacco is no like other
hazard. It is unique in its ability to kill you.
"The studies we have had coming from different populations all
show, if you start smoking in your teenage years and continue
to do so systemically, you will have about a 50 per cent chance
of being killed by tobacco. There is no other exposure or addiction
that produces that sort of risk, with the single exception of
HIV.
"The tobacco industry is likely to argue that there are other
mortal risks people face, such as getting struck by a lightning
or getting run down by a car. But these risks are much smaller
than those posed by tobacco. We must, as societies, and as public
health organizations, focus the attention of people and governments
on the fact that the risk from tobacco is like no other public
health concern.
"While alcohol abuse is a major cause for social disruption and
premature mortality, the projected epidemic of alcohol abuse is
not nearly as alarming as the projections we have concerning tobacco.
I am not saying that we should minimize alcohol as a public health
concern, but it is of a different nature. Similarly, drugs kill
people, the related risk of HIV is high, and drugs are a cause
of violence. But in terms of their public health impact drugs
are a far less of a substantial problem than tobacco, or for that
matter alcohol."
Looking to the future
Lopez describes his vision of the trends and challenges that lie
ahead.
1. Better communications
"Although we have the necessary information, many people, especially
politicians, have other agendas. "
"We have the information, but we still need a far more effective
communication mechanism. We are making the projections but have
not been effective in communicating them to policy makers and
to smokers themselves. Although we have the necessary information,
many people, especially politicians, have other agendas."
2. Cessation
"A lot of people die from tobacco use. They are not only old people,
but also the middle-aged. Exposure to tobacco is most likely to
be problematic when you are a teenager.In addition, young people
are often rebellious and like to experiment. Tobacco is an easy
legal substance to experiment with. Tobacco cessation has to be
far more effective means to young adults, who already are addicted
to tobacco."
3. Prevention
"A major concern of WHO has been to prevent tobacco use among
young people. The social environment is crucial. Countries are
using legislative mechanism to prevent smoking and this has a
snowball effect. The more you restrict the places and possibilities
to use tobacco, the less people will smoke."
4. Changing attitudes
"Very important changes in general attitudes towards tobacco use
have come about, for instance in the United States and Finland.
Two or three decades ago, smoking was socially acceptable behaviour.
Now, it is socially abnormal behaviour. Society itself is taking
steps to supporting legislative measures. Individual smokers are
reminded that smoking is a hazardous habit."
5. Smoking is additive behaviour
"There is an important trend in WHO: smoking is being viewed as
addictive behaviour, as is cocaine or heroin use, or alcohol consumption.
This approach deals with smoking in the social context. Besides
the physiological and psychological aspects, smokers will be increasingly
associated with the issue of addiction. Certain attributes are
being increasingly linked to addictive behaviour, such as weakness
and disappointment. This brings in the societal reaction to tobacco."
6. Women
Passive smoking is the question the tobacco industry is probably
mostly concerned about. The industry does not want passive smoking
to become a major public health issue, because it could entail
massive legal implications.
"The tobacco epidemic among males is not on the rise. But what
we are likely to see in the future is a rapid rise of smoking-related
deaths among women. It is important to ensure women and girls
in developing countries smokefree lives."
7. Passive smoking
"This is the question the tobacco industry is probably mostly
concerned about. The industry does not want passive smoking to
become a major public health issue, because it could entail massive
legal implications. I believe that scientific work on environmental
tobacco smoke will be considerably strengthened." n
Interview by Satu Lipponen
Smoke Free Europe - A Forum for Networks - 14 AUG 1997[Next] [Previous] [Up] [Top] [Contents] [Index]