3.36 The global tobacco pandemic

Last updated: April 2015

Suggested citation: Bellew, B, Greenhalgh, EM & Winstanley, MH. 3.36 The global tobacco pandemic. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2015. Available from http://www.tobaccoinaustralia.org.au/3-36-the-global-tobacco-pandemic


According to a recent review of mortality trends, world life expectancy is currently slightly above 70 years; most deaths earlier than that are avoidable, and are primarily caused by non-communicable diseases.1 Although communicable diseases, for example influenza and influenza-like illnesses, have a tendency to capture news headlines and possibly the attention of policy-makers more dramatically than many other health issues, an examination of the disease burden of influenza2-5 compared with the disease burden of tobacco6-8 leaves little doubt about the salience of tobacco as an issue in global public health. Death and disease caused by tobacco use now constitutes a pandemic;  its use is the leading cause of preventable death and is estimated to kill more than five million people each year worldwide.9-11 This constitutes one death about every six seconds.12 In 2004, 12% of all deaths worldwide among adults over 30 were attributed to tobacco.12 In 2010, smoking caused about a quarter of all cancer deaths in Europe and America, and even greater numbers from other diseases. Smoking is also a major cause of death in China, India, and other countries throughout Asia.1 In several Asian and African countries, more than 25% of male deaths are now related to smoking, matching regions in Europe and North America that previously had the highest proportion of tobacco-related mortality. More than two thirds of tobacco deaths occur in low- and middle-income countries,13 with the gap in deaths between low  and middle income countries and high income countries expected to widen further over the next several decades if effective prevention measures are not implemented.9 If current trends persist, tobacco will kill more than eight million people worldwide each year by the year 2030,14 and about 1 billion by the end of this century.13 

By 2030, it is projected overall that there will be approximately 26 million new cancer cases and 17 million cancer deaths per year.15, 16 This compares with about 12 million new cases and 7.6 million cancer deaths estimated to have occurred globally in 2007. The projected increase will be driven largely by growth and ageing of populations and will be largest in low- and medium-resource countries. Under current trends, increased longevity in developing countries will nearly triple the number of people who survive to age 65 by 2050. This demographic shift will be compounded by entrenched modifiable risk factors such as smoking, which is the leading risk factor for cancer mortality in countries of low, middle and high income.15, 16 On the basis of current tobacco consumption patterns, it has been estimated that approximately 450 million adults will be killed by smoking between 2000 and 2050. At least half of these adults will die between 30 and 69 years of age, losing decades of productive life. Cancer and the total deaths due to smoking have fallen sharply in men in high income countries but will rise globally unless current smokers, most of whom live in low and middle income countries, stop smoking before or during middle age.17

Projections of global mortality and burden of disease from 2002 to 2030 have been undertaken by Mathers and Loncar using three scenarios–'baseline', 'optimistic' and 'pessimistic'.8 The projections highlight tobacco-related mortality and burden of disease as a major threat to public health and allow comparisons with other major threats to public health such as human immunodeficiency virus (HIV) infection18 or obesity.15,19,20 In these projections, global HIV/AIDS deaths rise from 2.8 million in 2002 to 6.5 million in 2030 under the 'baseline' scenario, which assumes that coverage with antiretroviral drugs reaches 80% by 2012. Under the 'optimistic' scenario, which also assumes increased prevention activity, HIV/AIDS deaths drop to 3.7 million in 2030. By contrast, total tobacco-attributable deaths rise from 5.4 million in 2005 to 6.4 million in 2015 and 8.3 million in 2030 under the 'baseline' scenario. Tobacco is projected to kill 50% more people in 2015 than HIV/AIDS, and to be responsible for 10% of all deaths globally.8

Tuberculosis (TB), HIV and chronic obstructive pulmonary disease (COPD) are burgeoning epidemics in developing countries. The link between TB and HIV is well established. Less well recognised is the strong relationship between tobacco smoking and the development and natural history of TB. These associations are of considerable relevance to public health and disease outcomes in individuals with TB. Moreover, tobacco smoking, a modifiable risk factor, is associated with poorer outcomes in HIV-associated opportunistic infections, of which TB is the commonest in developing countries. It is now also becoming clear that TB, like tobacco smoke, besides its known consequences of bronchiectasis and other pulmonary morbidity, is also a significant risk factor for the development of COPD.18 Almost 90% of COPD deaths occur in low- and middle-income countries, and it has been estimated that COPD will be the third leading cause of death in 2030 globally.13 Thus, the harmful synergistic interaction between TB, HIV, tobacco smoking and COPD in a large proportion of the world's population that deserves urgent attention in developing countries.18

International research on current smoking prevalence and behaviours among youth aged 13–15 has reported disturbing trends for the future. The Global Youth Tobacco Survey, assessing data from more than 130 countries and principalities, has found that:21

  • the gap in smoking rates between school-aged girls and boys is decreasing, a finding of particular importance for those countries in which smoking has previously been negligible among the female population,
  • use of tobacco products other than cigarettes is widespread,
  • a sizeable proportion of children who currently do not smoke are contemplating adopting the behaviour, and
  • children are widely exposed to secondhand smoke.

Each of these findings can be expected to have a significant impact on morbidity and mortality from tobacco use in forthcoming decades.21

While the current burden of death is distributed evenly between developing and industrialised countries,22 most of the future burden of death will occur in low and middle income countries, where more than 80% of the world's smokers live.23 Smoking rates are for the most part well in decline in Western Europe, the UK, the US, Canada, New Zealand and Australia. However in some countries in Asia, South America and Africa, the prevalence of smoking is still increasing.24,25 In China, home to one-third of the world's population, the death toll from smoking currently stands at about 800 000 per year and it has been estimated that smoking will cause three million Chinese deaths annually by the middle of this century.26 Tobacco smoking rates vary; men usually smoke more than women in overall consumption and in prevalence. Current available estimates are 49% for men and 8% for women in low and middle income countries, and 37% for men and 21% for women in high income countries.27 This is reflected in the proportion of mortality attributable to tobacco, which is higher among men than women.12 A series of country profiles on non-communicable diseases made available by the World Health Organization points out that since prevalence varies greatly, these country profiles provide a useful way of examining this aspect of the pandemic and are illustrative of the importance of tobacco as a cross-cutting risk factor for non-communicable diseases.28

The global tobacco pandemic is characterised by an escalating burden of death and disease that is increasingly being borne by developing countries; efforts to promote global health equity must therefore prioritise reductions in tobacco consumption.29 The scale of this global tobacco pandemic8, 15-18, 27, 30 and the globalisation of tobacco use31 provide a clear rationale for a global response such as that set out in the World Health Organization Framework Convention on Tobacco Control (FCTC)33 and the supporting MPOWER package.33 The World Health Organization's Report on the Global Tobacco Epidemic describes some of the progress achieved as a result of the FCTC, such as 739 million people in 31 countries being afforded protected by comprehensive smoke-free laws;34 but an earlier World Health Organization report also implicitly acknowledges that much more needs to be done because it notes that less than 10% of the world's population is covered by any one of the MPOWER measures by the year 2008.14 Chapman, while acknowledging that an acceleration of policy development in tobacco-control policy has been ushered in by the FCTC, has also noted the optional nature of some aspects of the treaty and thus the particular importance of intensified strategies in harm reduction, demand reduction, denormalisation of tobacco use (especially among health workers in nations where use remains high) as well as further efforts to regulate the tobacco industry (especially plain packaging, under-the-counter retail sales and the regulation of tobacco products).35

Chapter 1 provides international prevalence comparisons while Chapter 2 gives international comparisons on tobacco consumption. The global nature of the industry is covered in Chapter 10. The WHO Framework Convention on Tobacco Control is described in detail in Chapter 18.

Relevant news and research

For recent news items and research on this topic, click here.(Last updated April 2022)



1. Norheim OF, Jha P, Admasu K, Godal T, Hum RJ, et al. Avoiding 40% of the premature deaths in each country, 2010–30: Review of national mortality trends to help quantify the UN Sustainable Development Goal for health. The Lancet, 2014. Available from: http://www.sciencedirect.com/science/article/pii/S0140673614615919

2. Shrestha SS, Swerdlow DL, Borse RH, Prabhu VS, Finelli L, Atkins CY, et al. Estimating the burden of 2009 pandemic influenza A (H1N1) in the United States (April 2009-April 2010). Clinical Infectious Diseases 2011;52(suppl. 1):S75-82. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21342903

3. Guo RN, Zheng HZ, Li JS, Sun LM, Li LH, Lin JY, et al. A population-based study on incidence and economic burden of influenza-like illness in south China, 2007. Public Health 2011;125(6):389-95. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21616513

4. Dawood FS, Fiore A, Kamimoto L, Bramley A, Reingold A, Gershman K, et al. Burden of seasonal influenza hospitalization in children, United States, 2003 to 2008. The Journal of Pediatrics 2010;157(5):808-14. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20580018

5. Simmerman JM and Uyeki TM. The burden of influenza in East and South-East Asia: a review of the English language literature. Influenza and Other Respiratory Viruses 2008;2(3):81-92. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19453467

6. Seffrin J, Hill D, Burkart W, Magrath I, Badwe R, Ngoma T, et al. It is time to include cancer and other noncommunicable diseases in the millennium development goals. CA: A Cancer Journal for Clinicians 2009;59(5):282–4. Available from: http://caonline.amcancersoc.org/cgi/reprint/59/5/282

7. Abegunde DO, Mathers CD, Adam T, Ortegon M and Strong K. The burden and costs of chronic diseases in low-income and middle-income countries. The Lancet 2007;370(9603):1929-38. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18063029

8. Mathers CD and Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Medicine 2006;3(11):e442. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17132052

9. World Health Organization. WHO report on the global tobacco epidemic, 2008: the MPOWER package. Geneva: WHO, 2008. Available from: http://www.who.int/tobacco/mpower/en/index.html

10. US Department of Health and Human Services. The health consequences of smoking: a report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/index.htm

11. US Department of Health and Human Services. The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2006/index.htm

12. World Health Organization. WHO report on the global tobacco epidemic, 2009: implementing smoke-free environments. Geneva: WHO, 2009. Available from: http://www.who.int/tobacco/en/

13. The Tobacco Atlas, Smoking's death toll. American Cancer Society, World Lung Foundation; 2015. Available from: http://www.tobaccoatlas.org/topic/smokings-death-toll/

14. World Health Organization. WHO report on the global tobacco epidemic, 2009: implementing smoke-free environments. Geneva: WHO, 2009. Available from: http://www.who.int/tobacco/en/

15. Thun M, DeLancey J, Center M, Jemal A and Ward E. The global burden of cancer: priorities for prevention. Carcinogenesis 2010;31(1):100–10. Available from: http://carcin.oxfordjournals.org/cgi/reprint/31/1/100

16. Ferlay J, Shin HR, Bray F, Forman D, Mathers C and Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. International Journal of Cancer 2010;127(12):2893-917. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21351269

17. Jha P. Avoidable global cancer deaths and total deaths from smoking. Nature Reviews. Cancer 2009;9(9):655–64. Available from: http://www.nature.com/nrc/journal/v9/n9/full/nrc2703.html

18. van Zyl Smit R, Pai M, Yew W, Leung C, Zumla A, Bateman E, et al. Global lung health: the colliding epidemics of tuberculosis, tobacco smoking, HIV and COPD. European Respiratory Journal 2010;35(1):27–33. Available from: http://erj.ersjournals.com/cgi/content/full/35/1/27

19. Withrow D and Alter DA. The economic burden of obesity worldwide: a systematic review of the direct costs of obesity. Obesity Reviews 2011;12(2):131-41. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20122135

20. Kelly T, Yang W, Chen CS, Reynolds K and He J. Global burden of obesity in 2005 and projections to 2030. International Journal of Obesity 2008;32(9):1431-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18607383

21. Warren C, Jones N, Eriksen M and Asma S for the Global Tobacco Surveillance System (GTSS) collaborative group. Patterns of global tobacco use in young people and implications for future chronic disease burden in adults. The Lancet 2006;367(9512):749–53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16517275

22. Ezzati M and Lopez AD. Regional, disease specific patterns of smoking-attributable mortality in 2000. Tobacco Control 2004;13:388-95. Available from: http://tc.bmjjournals.com/cgi/content/abstract/13/4/388

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24. Hammond SK. Global patterns of nicotine and tobacco consumption. Handbook of Experimental Pharmacology 2009(192):3–28. Available from: http://www.springerlink.com/content/t353k255747342h6/

25. Shafey O, Dolwick S and Guindon G. Tobacco control country profiles. Atlanta, Georgia: American Cancer Society, World Health Organization, International Union Against Cancer, 2003. Available from: http://www.cancer.org/docroot/PRO/content/PRO_1_1_Tobacco_Control_Country_Profiles.asp

26. Liu B, Peto R, Chen Z, Boreham J, Wu Y, Li J, et al. Emerging tobacco hazards in China: 1. Retrospective proportional mortality study of one million deaths. British Medical Journal 1998;317:411-22. Available from: http://www.bmj.com/cgi/reprint/317/7170/1411

27. Slama K. Global perspective on tobacco control. Part I. The global state of the tobacco epidemic. International Journal of Tuberculosis and Lung Disease 2008;12(1):3-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18173869

28. World Health Organization. Noncommunicable diseases: country profiles 2011. Geneva: WHO, 2011, [viewed 17 September 2011] . Available from: http://www.who.int/nmh/publications/ncd_profiles_report.pdf

29. Collin J. Global health, equity and the WHO Framework Convention on Tobacco Control. Global Health Promotion 2010;17(suppl. 1):S73–5. Available from: http://ped.sagepub.com/content/17/1_suppl/73.full.pdf+html

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33. World Health Organization. MPOWER: a policy package to reverse the tobacco epidemic. Geneva: WHO, 2008. Available from: http://www.who.int/tobacco/mpower/mpower_english.pdf

34. World Health Organization. WHO report on the global tobacco epidemic, 2011: warning about the dangers of tobacco. Geneva: WHO, 2011. Available from: http://globalink.org/redirect/www.who.int/tobacco/global_report/2011/en/index.html

35. Chapman S. Global perspective on tobacco control. Part II. The future of tobacco control: making smoking history? International Journal of Tuberculosis and Lung Disease 2008;12(1):8-12. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18173870