Intended for healthcare professionals


Tobacco dependence should be recognised as a lethal non-communicable disease

BMJ 2019; 365 doi: (Published 21 May 2019) Cite this as: BMJ 2019;365:l2204
  1. Dan Xiao, professor1 2,
  2. Chen Wang, professor12
  1. 1WHO Collaborating Center for Tobacco Cessation and Respiratory Diseases Prevention, Tobacco Medicine and Tobacco Cessation Centre, Centre of Respiratory Medicine, China–Japan Friendship Hospital, Beijing, China
  2. 2Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
  1. Correspondence to: C Wang wangchen{at}

Reframing would extend the scope of tobacco control

Tobacco use is one of the main risk factors for non-communicable diseases, which are a major health threat globally. Despite worldwide efforts at tobacco control over several decades, the prevalence of smoking is still high: 22% of people aged 15 and older are smokers.1 In 2007 there were 1.1 billion smokers worldwide, and this number had not changed by 2015.2 China had an estimated 316 million smokers in 2015.3 Unless these smokers stop, one in two is likely to die from tobacco related illnesses.4

Despite the efforts of healthcare professionals and the political will demonstrated by interventions such as smoking bans in public places, tobacco taxes, and pictorial warnings of serious harm on cigarette packaging,2 most smokers have not been able to quit for good because of nicotine dependence.25 Nicotine physically alters the smoker’s brain, making quitting difficult.5

Dependence is overlooked

The American Psychiatric Association and the World Health Organization have for years argued that tobacco dependence is a disease. In 1980 the American Psychiatric Association listed tobacco dependence in the Diagnostic and Statistical Manual of Mental Disorders (DSM-3),6 and WHO recognised it as a substance use disorder in the International Classification of Diseases.7 But tobacco dependence is still often ignored, both in individuals and in prevalence studies of mental disorders.891011 The China Mental Health Survey, the World Mental Health Survey, and the WHO Comprehensive Mental Health Action Plan 2013-20 all fail to consider the large number of smokers with tobacco dependence who regularly attend hospitals for smoking related disorders but are unknown to psychiatric services.91011

Tobacco dependence is common,121314 with an estimated prevalence of 50% among current daily smokers.12 The highest evaluation to our knowledge is 90% of smokers are dependent.1314 Even the 50% estimate translates to more than half a billion dependent smokers worldwide and some 158 million dependent smokers in China alone. These numbers are comparable with the numbers affected by priority non-communicable diseases such as heart disease, stroke, cancer, chronic respiratory diseases, and diabetes.

Treating dependence is one of WHO’s key tobacco control strategies, enshrined in article 14 of the WHO Framework Convention on Tobacco Control. Adopted in 2003, the convention has been ratified by 181 countries, but few have implemented the recommendations of article 14 promoting treatment for tobacco dependence.2 Less than 20% of the world’s population currently have access to appropriate tobacco cessation services, and most of them are in high income countries.2

Health professionals can have a key role in helping smokers overcome their addiction.151617 But with even the most intensive treatments for dependence, just one in four smokers quits for at least a year.18 How to increase cessation rates remains a problem for healthcare professionals and services. WHO has not endorsed new and emerging tobacco and nicotine products, such as e-cigarettes, as cessation aids because of the scarcity and low quality of scientific evidence; it is not clear whether they help most smokers to quit or prevent them from doing so.19

Reframing the problem

Currently, tobacco dependence is listed in the latest ICD and DSM as a mental health disorder. However, because tobacco dependence affects a huge number of patients and contributes substantially to common chronic diseases, we need to start considering it as a chronic non-communicable disease on a par with hypertension, diabetes, or heart disease. Redefining tobacco dependence as a leading non-communicable disease would encourage the development of specific disease management programmes within healthcare systems, with objective monitoring and continuous assessment of outcomes. Such a move would also help develop and evaluate new treatments for tobacco dependence, encourage research, move tobacco dependence up the global health agenda, attract the attention of governments that have so far ignored WHO’s tobacco control framework, help low and middle income countries where most smokers live, and improve the prevention and control of other deadly important non-communicable diseases linked to smoking.

It is time to reframe tobacco dependence as a leading non-communicable disease. Explicit training in tobacco dependence as a mandatory component in medical education, residency fellowship training, and continuous medical education is essential so that all clinicians are involved in the management of tobacco dependence in their patient population by identifying, diagnosing and treating, or collaborating with specialist programmes depending on country specific circumstances. Changes in clinical systems relating to tobacco dependence would extend the scope of tobacco control, strengthen the implementation of the WHO framework, contribute to reducing premature mortality from non-communicable diseases by one third by 2030 as part of the UN’s sustainable development goals, and save lives.


  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare we have received funding from the National Key R&D Program of China (grant No 2017YFC1309400).

  • Provenance and peer review: Not commissioned; externally peer reviewed.


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