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Health Promotion and Disease Prevention Knowledge Gateway

A reference point for public health policy makers with reliable, independent and up-to date information on topics related to promotion of health and well-being.


Tobacco and Smoking

Both active and passive smoking have harmful effects on health and may cause cancer. All tobacco products contain a wide range of toxic and cancer-causing compounds.

Defining tobacco: tobacco products and routes of administration

All substances and products derived from the tobacco plant Nicotiana tabacum can be considered tobacco products. Within the health context though, tobacco products are those products entirely or partly made of the leaf of tobacco as raw material, which are manufactured to be used for smoking, sucking, chewing or snuffing ( WHO FCTC 2003 (pdf)). The main psychoactive ingredient in preparations of the tobacco plant is nicotine, a pharmacologically active, highly toxic alkaloid; other biologically active chemicals are also present (MeSH terms ' Tobacco products , tobacco' and ' nicotine '),( WHO lexicon 1994 (pdf)).

Directive 2014/40/EU (EU 2014 (pdf))(the Directive) defines tobacco as ‘leaves and other natural processed or unprocessed parts of tobacco plants, including expanded and reconstituted tobacco’ and tobacco products as ‘products that can be consumed and consist, even partly, of tobacco, whether genetically modified or not’. Based on their route of administration, tobacco products can be smokeless tobacco products including chewing tobacco, nasal tobacco and tobacco for oral use, and tobacco products for smoking, including manufactured products that can be consumed via a combustion process (like cigarettes, cigars, cigarillos, roll-your-own tobacco and pipe tobacco) or via a water pipe.

The Directive also covers novel tobacco products (tobacco products not falling into any of the previous categories and placed on the market after 19 May 2014; heated tobacco products are an example), herbal products for smoking not containing tobacco, and electronic cigarettes (products that can be used for consumption of nicotine-containing vapour).

Active smoking is ‘the deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand’ (MeSH term ‘ Smoking ’). Cigarette smoking is the most common way of using tobacco in Europe and in the European Union (EU), mainly as commercially manufactured and as hand-rolled cigarettes (Special Eurobarometer 458, 2017). Other forms of smoking, such as pipe smoking, cigarillos or water-pipe smoking are much less prevalent in the EU. Smokeless tobacco products are rarely used in the EU, with some exceptions. Sales of tobacco for oral use are banned across the EU, except for the sale of snus in Sweden, where it is the most common form of tobacco (Special Eurobarometer 458, 2017). To a lesser extent, chewing or nasal tobacco (snuff) are also rarely sold and used in the EU. For the purpose of this webpage, active smoking refers to cigarette smoking, unless specified otherwise.

Environmental tobacco smoke (ETS) or second-hand smoke (SHS) is the mixture of mainstream tobacco smoke (exhaled by the active smoker), side-stream tobacco smoke (emitted from the cigarette between puffs), and other contaminants ( EC/IARC 2015 (pdf)). Tobacco smoke is a complex mixture containing toxic and carcinogenic substances in a vapour and a particulate phase. Substances include carbon monoxide, acetaldehyde, nitric oxide, polycyclic aromatic hydrocarbons (PAHs), N-nitrosamines, formaldehyde, and nicotine ( IARC 2012 ). Third-hand smoke consists of substances that are re-emitted from solid surfaces after having been deposited there during smoking and after SHS has been emitted into the air. Passive smoking is either the exposure to second- or third-hand smoke, or the exposure in utero to maternal blood that contains contaminants of tobacco smoking products ( ERS 2013 ) .

Active and passive tobacco smoking: effects on health

Both active and passive smoking have harmful effects on health and may cause cancer ( IARC 1986 ),( IARC 2004 ), ( IARC 1985 ),( IARC 2007 (pdf) ) . All tobacco products contain a wide range of toxic and cancer-causing compounds ( IARC 2012 ),( IARC 1986 ). The evidence supporting the 4th Edition of the European Code against Cancer states that tobacco use, and in particular cigarette smoking, is the single largest preventable cause of cancer in the EU. According to the European Cancer Information System estimates, in 2020 almost 260,000 people may have died in the EU from lung cancer (ECIS). Cigarette smoking is estimated to cause 82% of lung cancer cases in Europe ( EC/IARC 2015 (pdf)). Exposure to SHS has also been established to cause lung cancer ( IARC 2004 ).

The link between smoking and lung cancer was confirmed in the early 1950s ( WHO 2005 (pdf) ), and the first reports on smoking and health were published in the 1960s ( RCP 1962 )( HHS 1964 (pdf)). Evidence has been mounting ever since about the negative effects of smoking on various aspects of health, as the main risk factor for lung cancer and for chronic obstructive pulmonary disease (COPD) (HHS 2014 (pdf) ) , and these effects are summarised in Table 1 (active smoking) and Table 2 (passive smoking). Tobacco smoking contributes to overall health inequities in Europe, with mortality from smoking-related conditions largely explaining inequities in mortality between high and low socioeconomic groups, particularly in men ( WHO 2014 pdf).

Nicotine creates addiction, leading to the prolonged exposure to tobacco smoke of the smoker, increasing their risk for disease. People typically begin to smoke at a young age and may continue to smoke for decades. Nicotine has both stimulant and relaxing effects; users develop tolerance and dependence to nicotine, and a withdrawal syndrome appears in physically dependent users, when use is reduced or discontinued (MeSH terms ' Tobacco products , tobacco' and ' nicotine '). Nicotine dependence disorder (6C4A.2) is classed under ‘disorders due to use of nicotine’ in ICD-11 ( WHO 2018 ).

Smoking cessation is beneficial at any age, as it improves health status and quality of life. Smoking cessation not only reduces the risk of premature death, but also the risk for many adverse health effects such as reproductive health outcomes, cardiovascular diseases, COPD, and cancer ( HHS 2020 (pdf)). Smoking cessation is also beneficial for mental health, including in people with a mental health condition ( PHE 2020 ). Health outcomes of smoking cessation are summarised in Table 3.

Table 1. Effects of active tobacco smoking on health 

Table 2. Effects of passive smoking on health 

Table 3. Effects of smoking cessation on health 

Prevalence of tobacco smoking across European countries

In 2017, 26% of people in the EU were current smokers (30% of men and 22% of women) and 20% were ex-smokers. Wide differences exist between EU Member States in their prevalence of smoking habits; the prevalence of smoking varies between 7 and 37%, and that of being an ex-smoker between 13 and 41% (Table 4)(Special Eurobarometer 458, 2017). In most EU Member States, smoking rates are much higher in low socioeconomic status groups compared to high socioeconomic status; smoking is more frequent among people with lower education and less income ( WHO 2019 (pdf)) .

The 2019 European School Survey Project on Alcohol and other Drugs (ESPAD) survey ( EMCDDA/ESPAD 2020 ) estimated prevalence of smoking in the last 30 days among 15- to 16-year-old students ranged between 10% and 32% in EU Member States.

Exposure to SHS among European children aged 13 to 15 has decreased from 2002 to 2017 both at home and in other enclosed public spaces ( WHO 2019 (pdf)). Table 5 presents self-reported exposure to second-hand smoke in the last visit to drinking or eating establishments in EU Member States in 2017 ( Special Eurobarometer 458, 2017 ).

Table 4. Percentage of Europeans self-reporting as active or ex-smokers 

Table 5. Percentage of Europeans self-reporting being exposed to second-hand smoke 

Health and economic burden related to tobacco smoking

Tobacco use is among the leading risk factors for global mortality. The Global Burden of Disease (GBD) Study estimated that, in the EU, tobacco use (including tobacco smoking, tobacco chewing and exposure to second hand smoke) accounted for over 907,000 deaths and over 22,150,000 Disability-Adjusted Life Years (DALYs) in 2019; most of this burden is caused by active tobacco smoking. Second-hand smoking, in turn, accounted for over 73,000 deaths and almost 1,760,000 DALYs. It was estimated that chewing tobacco accounted for 261 deaths and over 5,800 DALYs in the EU during 2019 ( GBD tool ).

The global economic cost of smoking-attributable diseases in 2012 ( Goodchild et al. 2018 ) was estimated at purchasing power parity (PPP) $1852 billion, equivalent to 1.8% of the world’s annual gross domestic product (GDP). In 2009, tobacco smoking cost €544 billion the EU (EU/DG SANCO 2012 (pdf)), about 4.6% of the EU27 combined GDP. The burden of tobacco falls disproportionately on those with a lower socioeconomic status, and is a source of both health and economic disparities, regardless of a country’s stage of economic development ( ACS (pdf)).

View visualisation: smoking burden of disease - DALYs map and data table 

View visualisation: smoking burden of disease - Mortality map and data table 

View visualisation: tobacco burden of disease - DALYs map and data table 

View visualisation: tobacco burden of disease - Mortality map and data table 

View visualisation: second hand smoke burden of disease - DALYs map and data table 

View visualisation: second hand smoke burden of disease - Mortality map and data table 

Addressing tobacco use: recommendations and implemented policies

Tobacco control policies cover supply, demand, and harm reduction policies, and some countries have extended them to cover nicotine in any form. These measures aim to reduce the prevalence of tobacco use and the exposure to tobacco smoke. Tobacco control plays an important role in achieving Sustainable Development Goal (SDG) target 3.4 (reducing premature deaths from non-communicable diseases by one third by 2030), and contributes to achieving other SDGs related for example to poverty, hunger, economic development, or environmental sustainability ( WHO 2019 (pdf)).

The WHO Framework Convention on Tobacco Control ( WHO FCTC 2003 (pdf)) is a comprehensive global effort to cover all these aspects. The implementation of the WHO FCTC relies on a series of guidelines, policies and recommendations ( WHO FCTC adopted ) and on the six MPOWER measures ( WHO 2008 (pdf)), which consist of effective interventions proven to reduce demand for tobacco products. An overview to the WHO FCTC can be found here:

Overview of the WHO Framework Convention on Tobacco Control 

The European Union ratified the WHO FCTC in 2005, and has been implementing tobacco control measures across the Member States ever since.

Examples of policy recommendations to reduce tobacco use and its consequences, as well as related implemented policies, are listed in table 6.

Overview of Directive 2014/40/EU 

Examples of national and international policy recommendations and implemented policies aiming to decrease tobacco use or exposure to tobacco smoke 


Overview of the references to this brief