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BMJ No 7108 Volume 315 News Saturday 6 September 1997 The 10th world conference on tobacco or health was held in Beijing last month. Richard Tomlinson reports Smoking death toll shifts to third world The ever rising number of deaths from tobacco related disease will shift markedly from the developed to the developing world over the next three decades. Grim statistics presented by Richard Peto, professor of medical statistics at Oxford University, estimated that annual tobacco related deaths worldwide had been 3 million a year in 1990, rising to 3.5 million this year, and would hit 10 million some time between 2025 and 2030. Most marked was the huge jump expected in poorer countries. In 1990 about one million tobacco related deaths were in the developing world, but this would increase to 7 million soon after 2025. The large gains in combating infectious diseases in the developing world were at risk of being eclipsed by smoking related deaths, the conference was warned. Professor Peto highlighted new data for China which showed that the tobacco epidemic had developed faster than had been earlier forecast. New studies estimated that there were already 0.7 million tobacco related deaths a year in China (0.6 million in men and 0.1 million in women). "China already has more tobacco deaths than any other country," said Professor Peto. By 2025, he expected up to 3 million tobacco related deaths a year in China. Professor Judith Mackay, the Hong Kong based director of the Asian Consultancy on Tobacco Control, said that there are currently 1.1 billion smokers worldwide, but she estimated that by 2025 this would grow to 1.64 billion owing to longer lifespans, bigger populations, and more women smokers. The number of smokers in developing countries would rise from 800 million now to 1.4 billion by 2025. Healthcare facilities in poorer countries would be "hopelessly inadequate" to cope, she said. More research into the effects of tobacco in the developing world is also needed. Professor Peto pointed out that the pattern of tobacco related deaths in China is very different from that in the West. Some 45% of tobacco related deaths in China involved chronic obstructive pulmonary disease, compared with 15% in developed countries. Lung cancer accounted for 15% of China's tobacco related deaths compared with 25% in the West. Stroke and ischaemic heart disease each accounted for 5-8% of the deaths, whereas in the West these together account for nearly half, he said. Tobacco related liver and stomach cancers were also far higher in China. US settlement harms rest of the world The proposed $368.5bn (£230bn) legal settlement between 40 states and the tobacco industry in the United States was heavily criticised for doing nothing to limit the activities of the tobacco giants abroad. The tobacco deal (26 April, p 1217) was the hottest political subject at the conference, and organisers said that no other topic had prompted as many submissions. As the domestic market has declined over the past 20 years, cigarette exports have quadrupled - nearly one third of the cigarettes made in the United States are exported. "If the settlement goes through, we have the potential to see children on the streets of Manila today paying for Mississippi medical bills in 10 to 20 years time," said Gregory Connolly, director of the Massachusetts tobacco control programme. The final conference resolution avoided naming the United States directly but called for governments to ensure that any tobacco settlements "do not contribute to an increase in the worldwide epidemic of tobacco related death and disease." Settlements should "not inhibit full public scrutiny of the past, present, and future activities of the tobacco industry" and must protect the legal rights of those not party to the agreement. Stanton Glantz, professor of medicine at the University of California, and an outspoken critic of the American settlement, said: "If you apply these standards to the US deal, it does not come close to passing." Frank Chaloupka, an economist at the University of Illinois, said that when American cigarette companies used trade legislation to force open the markets of South Korea, Thailand, Taiwan, and Japan in the 1980s the result was a surge in tobacco advertising and an increase in smoking rates. Economic argument is the key to tobacco control Establishing the real economic impact of smoking is the key to persuading developing countries to adopt tobacco control measures, said Professor Judith Mackay, director of the Asian Consultancy on Tobacco Control. "What do we [the tobacco control lobby] most need in Asia? We need an economist," she told the conference. Professor Mackay, who works with almost every country in Asia, said that fear of the economic impact of reducing smoking was the biggest barrier she faced. "The governments are saying: what about the tax coming in, what about our tobacco farmers, what about the economy?" "Governments need to understand that tobacco control is not only good for health, but it is actually good for the economy," Professor Mackay said. Prabhat Jha, a public health specialist at the World Bank, said that the global net economic cost of tobacco was now at least $200bn (£125bn) a year, equivalent to 1% of global gross domestic product. One third of that net loss was already incurred in developing countries. China, where tobacco tax is the largest industrial source of government revenues, is one country that has conducted detailed economic studies. In 1993, tax revenues from cigarettes were 41 billion yuan (£3.15bn), but total direct and indirect economic losses were estimated at 65 billion yuan. "It's exquisitely important to have that kind of economic analysis from the point of getting tobacco control action in place," said Professor Mackay. Home | Current issue | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline