Smoking - statistics

More than half a century ago, the causal link between lung cancer and tobacco smoking was established. 1-5 Since then a wealth of information has been assembled on the tragic health consequences of tobacco consumption and the highly addictive nature of nicotine in cigarettes which makes smoking cessation so difficult. Today, tobacco consumption is recognised as the UK’s single greatest cause of preventable illness and early death with around 107,000 people dying in 2007 from smoking-related diseases including cancers. 6

Around 86% of lung cancer deaths in the UK are caused by tobacco smoking and, in addition, the International Agency for Research on Cancer (IARC) states that tobacco smoking can also cause cancers of the following sites: upper aero-digestive tract (oral cavity, nasal cavity, nasal sinuses, pharynx, larynx and oesophagus), pancreas, stomach, liver, bladder, kidney, cervix, bowel, ovary (mucinous) and myeloid leukaemia. 7

Overall tobacco smoking is estimated to be responsible for more than a quarter of cancer deaths in the UK, that is, around 43,000 deaths in 2007. 6

Tobacco was first introduced to Britain in the sixteenth century when it was commonly smoked in pipes by men. Later snuff-taking and cigar smoking became popular among men but it was the invention of cigarette-making machines in the latter part of the nineteenth century that made mass consumption of tobacco possible.

By 1919, more tobacco was sold as cigarettes than in any other form of tobacco. 9 At first only men smoked cigarettes and their consumption rose steadily until 1945, when it peaked at 12 manufactured cigarettes per adult male per day.

After the Second World War there was a slight dip in consumption, but thereafter it remained at around 10 manufactured cigarettes per day until 1974 which marked the start of a steady and continuous decrease to 4.6 manufactured cigarettes per adult male per day in 1992. 9

Women began to smoke cigarettes in the 1920s but not in large numbers until after the Second World War, by which time they were smoking 2.4 cigarettes per adult female per day. Consumption continued to increase until it reached 7.0 cigarettes per day in 1974; it then declined to 3.9 cigarettes per day in 1992.

In Britain in 1948, when surveys of smoking began, smoking was extremely prevalent among men: 82% smoked some form of tobacco and 65% were cigarette smokers. By 1970, the percentage of cigarette smokers had fallen to 55%. From the 1970s onwards, smoking prevalence fell rapidly until the mid-1990s. Since then the rate has continued to fall slowly and in 2007 around a fifth (22%) of men (aged 16 and over) were reported as cigarette smokers. Since 2007, the rate has remained stable ( Figure 6.1). 9, 10   In 2009, only 2% of men reported being cigar smokers and less than 0.5% of men said they smoked a pipe.10   Trends in lung cancer incidence rates (shown here from 1975 onwards) reflect the trends in smoking prevalence in past years.

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Smoking has never been a majority habit among women and the percentage of female smokers remained remarkably constant between 1948 and 1970 (41% in 1948 and 44% in 1970). By 2007, the percentage of women who smoke decreased to 20%. In 2008, it increased to 21%, and the difference in smoking prevalence between men and women in Britain was not significant. Female smoking prevalence fell to 20% in 2009, slightly lower than male prevalence in that year ( Figure 6.1).10  

Around 10 million adults in Britain smoke cigarettes. 11

Recent research suggests that self-reported cigarette smoking rates may underestimate true tobacco smoking prevalence by 2.8% in England. 12

In Great Britain, since the early 1990s, the highest rates of smoking have been in the 20-34 age-group, but in 2009 the rate in this age group was the same as the rate among 35-49-year olds (25%). The lowest prevalence of smoking is found among adults aged 60 and over, at 14% in 2009 ( Figure 6.2). 10 The difference between the age groups has historically been smaller and has increased as the result of higher smoking cessation rates amongst older people. For example, in 1974 34% of people aged 60 and over smoked and this has more than halved to 14% in 2009, whereas the decrease for people aged 20-24 over the same time period is from 48% to 26%.

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Before the dangers of cigarette smoking were widely known, smoking prevalence varied little by socio-economic group. Today there are clear differences due to the differential decline in smoking by social class that occurred in the 1970s and 1980s. 10

In 2009, 26% of adults in manual households smoked compared to 16% of those in non-manual households ( Figure 6.3). 10 The difference between managerial and professional households and routine and manual households is even greater (15% compared to 29%).10

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Manual workers start to smoke at an earlier age, with 48% of men and 40% of women in routine and manual occupations in Britain regularly smoking by 16 compared with 33% of men and 28% of women in managerial and professional occupations, according to the results of the 2005 General Household Survey. 49

Smoking is a key contributory factor to health inequalities between socio-economic groups in the UK and accounts for a major part of the differences in life expectancy between manual and non-manual groups. Recent Government targets are to reduce adult smoking rates to 21% or less by 2010, with a reduction in routine and manual groups to 26% or less. 13

Smoking rates vary considerably between ethnic groups and between men and women within those groups ( Figure 6.4 ). 14

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In men, smoking rates ranged from 20% (Indian) to 40% (Bangladeshi) compared with the national average of 24%. In women the rates ranged from 2% (Bangladeshi) to 26% (Irish) compared with the national average of 23%. 14

When smoking data are age-standardised, Bangladeshi and Irish men were still more likely to smoke than the general male population (standardised risk ratio (SRR) 1.43 and 1.30 respectively) while Indian men were less likely (SRR 0.78). After age-standardisation, no female minority ethnic group was more likely to smoke than the general female population, and Black African, South Asian and Chinese women were less likely to smoke. However, while few Bangladeshi women report that they smoked cigarettes, 16% chew tobacco which is associated with high rates of oral cancer.

As with the general population, smoking prevalence in minority ethnic groups tends to decrease with age with the highest rates in those aged 16-34. Exceptions are Black Caribbean and South Asian men in whom prevalence is highest in those aged 35-54.

In the general population male smoking prevalence fell from 27% to 24% between 1999 and 2004. There were also significant decreases among Black Caribbean (35% to 25%) and Irish men (39% to 30%) and Irish women (33% to 26%) but there were no significant decreases in the other ethnic groups.

As the above smoking prevalence rates are based on self-reported data, it is likely that they are underestimates. Saliva cotinine samples provide evidence of higher rates. For example, self-reported use of tobacco products was 44% and 17% for Bangladeshi men and women respectively, while cotinine levels suggest levels of 60% for men and 35% for women. 14

In Britain, Scotland has the highest smoking prevalence rate at 25% in 2009, followed by Wales (23%) and England (21%). 10,15 Within England, prevalence is highest in the North West and lowest in the South West ( Figure 6.5). 10

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Smoking prevalence varies widely around the world and is increasing rapidly in many developing countries, creating huge health problems for the future if unchecked. Worldwide approximately 1.3 billion people currently smoke cigarettes or other tobacco products. 16

The majority of the world’s smokers (80%) live in low or middle income countries. By 2025/30, it is estimated that 10 million people will die annually from smoking-related diseases, 70% of these deaths in developing countries. 17

A model of the worldwide tobacco epidemic ( Figure 6.6), describes first the rise and decline in smoking prevalence, followed by a similar trend for smoking-related diseases. 18

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The UK and other westernised countries are in the fourth stage of the tobacco epidemic with smoking prevalence below 30%. In Asia, which contains a third of the world’s population and over half the world’s smokers, male smoking prevalences are in excess of 50%, for example, 53% in Japan, 63% in China and 73% in Vietnam. 18, 19 In China alone, 600,000 smoking-related deaths occur annually and it is estimated that one-third of all young men in China will be killed by tobacco if current smoking rates continue. 20

Not all countries fit the model perfectly, for example the characteristic increase in female smoking rates in the second stage has not occurred in China where female smoking prevalence remains below 5%. However, the model allows each country ‘to find itself in relation to the larger pandemic’ and to take the necessary action to interrupt the natural relationship between tobacco consumption and death. 16

Within the EU there is wide variation in smoking prevalence from around 18% in Sweden to 42% in Greece. 21 The average for the 25 countries of the EU was 32%. 21

Many northern European countries are in the fourth stage of the tobacco epidemic, with falling smoking rates and widening socioeconomic differences in smoking. Southern European countries have mostly reached the third stage of the tobacco epidemic.

Of particular concern, is the fact that in most countries young people more likely to be current smokers than older people. 22 A striking contrast can be seen between older and younger women in Spain and to a lesser extent in Portugal: fewer than 5% of Spanish women aged 45-74 smoke compared to nearly 40% of young (25-44) women in Spain.

While less than 1% of 11 and 12-year old children smoke, by the age of 15 years, 12% of children in England report being regular smokers 23 despite the fact that it is illegal to sell any tobacco product to under 18s. There is evidence that actual smoking rates among 15-year olds may be higher than reported, based on measurements of cotinine in saliva, with 21% of 15-year old boys and 19% of 15-year old girls having cotinine levels indicative of active smoking. 24

In 2010, 5% of children aged 11-15 years smoked at least one cigarette each week: 6% of girls and 4% of boys. This is a similar proportion to 2009, and maintains the decline recorded since the mid-1990s. 23

Since 1986, girls have had consistently higher rates of smoking than boys: in 2010, 14% of 15-year old girls were regular smokers compared to 10% of boys ( Figure 6.7). 23 The proportion of 15-year-olds in Scotland smoking regularly in 2010 was similar to England (11% of boys and 14% of girls).51 The proportion of female smokers in Britain taking up the habit before the age of 16 increased from 28% in 1992 to 37% in 2009, while among men, this proportion remained at around 40% over the same period.10 On average, regular child smokers smoke 37 cigarettes per week. 23

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The adolescent years are extremely important in establishing an individual’s lifetime smoking or non-smoking behaviour. Factors that encourage children to smoke include having parents, siblings and peers who smoke; being in a one-parent family; having a poor academic record and being exposed to tobacco advertising.

Children become addicted to the nicotine in cigarettes in the same way as adults and experience the same withdrawal symptoms. In addition, there is evidence that a younger age of smoking initiation increases the risk of lung cancer independently of the amount smoked or duration of smoking. 26

Research has consistently shown that non-smokers are put at risk by exposure to other people’s smoke. 27 This may be called passive or involuntary smoking and is also referred to as secondhand smoke (SHS) or environmental tobacco smoke (ETS).

Tobacco smoke is made up of ‘sidestream’ smoke from the burning tip of the cigarette and ‘mainstream smoke’ from the filter or mouth end: it is the sidestream smoke that makes up the majority (85%) of ETS. The government’s Scientific Committee on Tobacco and Health (SCOTH) concluded in 1998 that ETS caused lung cancer and heart disease in adult non-smokers. 28

The most recent meta-analyses have confirmed these findings and estimate that non-smokers exposed to passive smoking at home or in their occupation have their risk of lung cancer raised about a quarter, while heavy exposure at work doubles the risk. 29, 48

Passive smoking also contributes to continuing the “family circle” of smoking and there is much evidence of the harmful effects on children in ‘smoking’ households including respiratory disease, asthma attacks, cot deaths and middle ear infections. 30 The Acheson report highlights the fact that while one third of children in the UK live with at least one adult smoker, among low-income families the figure is 57%. 31

Smoking during pregnancy increases the risk of spontaneous abortion, preterm birth, low birth weight and stillbirth. 30   In addition, IARC states that there is sufficient evidence that parental smoking (mother and father) during the preconception period and pregnancy increases risk of hepatoblastoma in offspring, and limited evidence that parental smoking increases risk of childhood leukaemia in offspring. 50

In 2005, 32% of women smoked in the year before or during pregnancy (a fall from 35% in 2000) and 17% ( a fall from 19% in 2000) smoked throughout pregnancy. 32 The rates were even higher for mothers in routine or manual jobs: 48% smoked in the year before pregnancy or during and 29% throughout pregnancy compared to mothers in managerial or professional jobs whose equivalent percentages were 19% and 7%. 32

The targets set out in ‘Smoking Kills’ include reducing the percentage of women who smoke during pregnancy from 23% in 1996 to 15% by 2010 with an interim fall to 18% by 2005. 33

It is estimated that exposure to ETS in the home causes around 11,000 deaths in the UK each year from lung cancer, stroke and ischaemic heart disease. 34

In Scotland out of the 865 annual deaths caused by ETS, an estimated 5% (44) are from lung cancer. 35 Applying this percentage to the UK, an estimated 600 deaths from lung cancer may be caused each year by ETS. The case for reducing exposure to ETS is incontrovertible and led to legislation in England making enclosed public places and workplaces smokefree from 1st July 2007, following earlier legislation in Scotland, Wales and Northern Ireland.

It is estimated that one in two regular cigarette smokers will eventually be killed by their tobacco habit, half of these in middle age. 36 Over the last 50 years, six million Britons have died from tobacco-related diseases, three million of whom died in middle age (15-69) losing on average 20 years of life. If current smokers can be encouraged to quit, mortality during the first half of the twenty-first century will be reduced: discouraging young people from starting to smoke will reduce smoking-related deaths during the middle or second half of the twenty-first century.

A range of measures is needed to tackle the tobacco problem and the Department of Health’s policy on reducing deaths due to smoking has identified six areas for action:

• reducing exposure to ETS
• education
• reducing availability of tobacco products and regulating supply
• help for the individual to stop smoking
• reducing tobacco advertising and promotion
• and regulating tobacco products. 37

The introduction of Smokefree legislation in the UK was complete by July 1 2007 as described in the section above on Passive smoking. Many charities and professional organisations as well as the government are involved in educating the public on the dangers of smoking, in particular targeting the more socioeconomically deprived groups who have the highest smoking rates.

Price increases have proved to be an effective measure for reducing smoking. On average, a price increase of 10% on a packet of cigarettes reduces consumption by about 4% in developed countries. However, price control is undermined by tobacco smuggling which currently accounts for 16% of the UK market. 38

Tobacco advertising, promotion and sponsorship is banned in the UK. 39 Health warnings have to cover 30% of the front and 40% of the back of tobacco packaging, while terms such as ‘low-tar’ and ‘light’ are prohibited. 40 Maximum yields are set on the amounts of tar (10mg), carbon monoxide (10mg) and nicotine (1mg) in cigarettes. 40

Between 1970-2000, British men experienced the most rapid decrease in death rates from tobacco in the world as a result of smokers quitting the habit. 41 Over two-thirds (67%) of current British smokers would like to give up smoking. 41

To help smokers to quit smoking, the government set up the NHS Stop Smoking Service, in 1999/00, following recommendations of the White Paper Smoking Kills in 1998. 42 Between April and September 2006 nearly a quarter of a million (246,254) people in England set a quit date through NHS Stop Smoking Services. 43

The majority of these people received nicotine replacement therapy. Around half were still non-smokers at four weeks. Removing the large differences in smoking rates between socio-economic groups was first targeted in the Cancer Plan 44 and later in the Public Service Agreement in 2004. 13

Smoking rates are currently only declining at less than 0.4% per annum in the UK 45, and, in order to meet the Government’s targets, a greater decline is needed. To achieve this a new comprehensive national strategy building on Smoking Kills is required. 46

Tobacco control is recognised as a global problem as tobacco companies target the developing world. In May 2003, the World Health Organisation (WHO) adopted the world’s first public health treaty, the Framework Convention on Tobacco Control (FCTC) to provide countries with the basic tools to enact comprehensive tobacco control legislation. The key provisions are shown in Table 6.1. 47 By 31 January 2007 143 countries had ratified the treaty which, if effectively implemented, offers the possibility of stemming the tobacco pandemic in the developing world.

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