Epidemiology

In 2021, approximately 35.6 million US adults (14.5% of the population) smoked tobacco products (including cigarettes, cigars, and pipes).[4] The prevalence of cigarette smoking is the lowest prevalence since data became available, but it remains unacceptably high.[4] The pattern in cigarette use among adults who smoke daily has also shifted, with adults generally smoking fewer cigarettes per day in 2021 than in 2005.[4] The prevalence of any current tobacco product use is higher among men (24.1%) than among women (13.6%).[4]

Globally, the prevalence of current use of smoking tobacco among individuals ages 15 years and older is 32.7% among males and 6.6% among females.[6] The regions with the highest prevalence of current smokers in men are east Asia (49.5%), Southeast Asia (48.2%), eastern Europe (44.7%), and Oceania (41.3%) and in women are central Europe (25.9%), Southern Latin America (23.3%), and western Europe (22.7%).[6]

The global prevalence of smoking during pregnancy is estimated to be 1.7%.[7] The highest prevalence of smoking during pregnancy is in Europe (8.1%).[7] In the US, 7.2% of women who gave birth in 2016 smoked cigarettes during pregnancy.[8] Prevalence of smoking during pregnancy was highest for women ages 20-24 years.[8]

Tobacco smoking usually begins in adolescence or early adulthood (typically before the age of 24 years).[9] Globally, prevalence of tobacco smoking among adolescents remains high, with prevalence of smoking among 13- to 15-year-olds found to be 19.33% on average, according to one large global study.[10] Higher-income countries have been found to have the highest prevalence of adolescent smoking globally, compared with lower-income countries.[10] However, in the US, a decline in cigarette smoking has been seen in young people under the age of 24 years since the late 1990s (from 29.1% to 5.4%).[11] Similar declines in the prevalence of smoking in adolescents have been seen in the UK across a similar time period.[12] Adolescents living in deprived parts of the UK have an approximately twofold higher risk of smoking compared with those living in the least deprived parts of the country.[12]

It is estimated that more than 8 million smoking-attributed deaths occur globally each year.[13] This includes almost 500,000 people in the US who die from smoking-related illnesses.[14] Most smoking-attributed deaths are due to cancer (34%), cardiovascular diseases (32%), or respiratory disease (21%), with nearly 90% of lung cancers and 80% of chronic obstructive pulmonary disease deaths caused directly by smoking.[14] Globally, the health outcomes with the largest number of deaths attributable to smoking tobacco use are ischemic heart disease; chronic obstructive pulmonary disease; tracheal, bronchus, and lung cancer; and stroke.[6][15]

Even light or mild smoking can carry significant morbidity. One study showed that a large proportion of the risk of coronary heart disease and stroke comes from smoking only a few cigarettes. This has important consequences for smokers who believe that light smoking carries little or no harm. It was shown that smoking one cigarette per day carries around 40% to 50% of the excess risk for developing coronary heart disease and stroke of smoking 20 cigarettes per day, and smoking 5 cigarettes per day has around 55% to 65% of the excess risk. No safe level of smoking exists for cardiovascular disease.[16]

Smoking reduces the median survival of smokers on average by 10 years, and beyond the age of 40 each additional year of smoking reduces life expectancy by 3 months.[17] By quitting cigarette smoking, a person reduces the risk of lung cancer and other diseases by 20% to 90% and improves survival, even among those who quit after the age of 50 years.[17] Nonetheless, habitual smokers find it extremely difficult to successfully quit smoking. Although 70% of smokers would like to quit, and 40% make at least one quit attempt per year, only 3% to 4% of smokers per year are successful in quitting long-term on their own.[18] There is substantial variation across countries in the percentage of smokers who reported making quit attempts, with the highest in Europe being England, where 46.3% of smokers reported making a quit attempt in the past 12 months.[19] A decline in the prevalence of quit attempts in England from 44.6% to 33.8% is likely to be associated with a decrease in the population-level prevalence of smokers with a high motivation to quit, and an increase in the mean age of smokers.[20] In a multinational survey of smokers on their most recent quit attempt, many respondents (38.6%) used no aid or assistance in their attempt to quit smoking and in those who did use assistance, nicotine substitution products (nicotine vaping products, nicotine replacement therapy) were the most common methods.[21]

No level of exposure to combustible tobacco smoking is considered safe. In 2017, 1.2 million deaths globally were attributable to secondhand smoke exposure, of which 63,822 occurred among children younger than 10 years old.[22] In the US, it is estimated that of the 20 million Americans who died because of smoking since 1964, 2.5 million were nonsmokers who died because of secondhand smoke.[23]

The epidemiology of nicotine e-cigarette use (vaping) is closely interconnected with that of combustible tobacco smoking. In adults in the US and Europe, a rapid increase in nicotine e-cigarette use has been seen since 2010; the vast majority of users are current or former smokers.[24][25][26][27] Nicotine e-cigarette sales and usage have increased substantially in recent years. In the US, during 2020-2022, monthly sales increased by 46.6%: from 15.5 million units in January 2020 to 22.7 million units in December 2022.[28] Population-based studies suggest that, overall, increasing nicotine e-cigarette use among adult smokers is associated with increases in smoking cessation rates.[29] However, among nonsmokers, use of nicotine e-cigarettes appears to increase the risk that an individual will initiate combustible cigarette smoking and become a current smoker; the magnitude of this risk is on average around threefold, according to one large meta-analysis.[30] In particular, concerns exist about the health risks associated with dual use of tobacco smoking and e-cigarettes, which exposes users to two sources that are harmful to health.[31][32] Dual tobacco smoking and nicotine e-cigarette use appears to be the most common pattern of e-cigarette use.[33] In the US, young adults (ages 18-24 and 25-44) are more likely than older adults to be dual users of both nicotine e-cigarettes and combustible cigarettes.[4] Nicotine e-cigarettes have the potential to benefit some adults as a complete substitute for cigarette smoking, although stances from professional medical bodies on this vary internationally.

Usage of nicotine e-cigarettes has increased dramatically in children and adolescents in recent years in countries including the US and UK.[34][35] Nicotine e-cigarettes are the most commonly used form of nicotine-containing product among high school and middle school students in the US (with 10.1% and 5.4% of students reporting use, respectively).[36] In England, current vaping prevalence in young people was 8.6% in 2022, compared with 4.1% in 2021.[35] A number of studies have found a strong association between e-cigarette use and subsequent smoking initiation among adolescents and young adults, although it is currently unclear whether this relationship is causal.[37][38][39] It has been suggested that increasing e-cigarette use among young people may be diverting them away from combustible tobacco smoking, although the evidence is mixed, and it may be that the two trends are in fact independent of each other.[11] Younger e-cigarette users are more likely to have never smoked cigarettes than older nicotine e-cigarette users.[40]

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