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 ( (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 ' , and ' '),( (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 ‘ ’). 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 ( (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 ( ). 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 ( ) .
Active and passive tobacco smoking: effects on health
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 ( ),( ). 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 ( (pdf)). Exposure to SHS has also been established to cause lung cancer ( ).
The link between smoking and lung cancer was confirmed in the early 1950s ( ), and the first reports on smoking and health were published in the 1960s ( )( (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) (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 ( 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 ' , and ' '). Nicotine dependence disorder (6C4A.2) is classed under ‘disorders due to use of nicotine’ in ICD-11 ( ).
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 ( (pdf)). Smoking cessation is also beneficial for mental health, including in people with a mental health condition ( ). Health outcomes of smoking cessation are summarised in Table 3.
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 ( (pdf)) .
The 2019 European School Survey Project on Alcohol and other Drugs (ESPAD) survey ( ) 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 ( (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 ( ).
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 ( ).
The global economic cost of smoking-attributable diseases in 2012 ( ) 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 ( (pdf)).
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 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 ( (pdf)).
The WHO Framework Convention on Tobacco Control ( (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 ( ) and on the six MPOWER measures ( (pdf)), which consist of effective interventions proven to reduce demand for tobacco products. An overview to the WHO FCTC can be found here:
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.
Reported intakea is based on publicly available data...
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