Avoidable global cancer deaths and total deaths from smoking

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Key Points

  • Currently, smoking causes approximately 5–6 million deaths per year, including 31% and 6% of all cancer deaths in middle-aged men and women, respectively. The proportions of male cancer and total deaths due to smoking are falling in high-income countries but rising in low- and middle-income countries.

  • Cessation by current smokers is the only practical way to avoid a substantial proportion of tobacco deaths worldwide before 2050.

  • Cessation before middle age avoids more than 90% of the lung cancer mortality attributable to smoking and markedly reduces the risks of death from other diseases. Although cessation has become common in high-income countries, it is still rare in most low- and middle-income countries.

  • Countries such as France that have aggressively used higher taxes to curb smoking have reduced consumption much faster than countries that have not aggressively increased tobacco taxation.

  • In low- and middle-income countries, a 10% higher tobacco price reduces consumption by around 8%, which is twice the effect seen in high-income countries. Health information, counter-advertising, restrictions on smoking and cessation therapies are also highly effective at reducing smoking.

  • A 70% higher street price of cigarettes (corresponding to around a 2–3-fold higher tax) would avoid 115 million deaths or one-quarter of expected tobacco deaths over the next few decades. Of the avoided deaths, approximately 25 million would be from cancer and 50 million from vascular disease.


On the basis of current consumption patterns, approximately 450 million adults will be killed by smoking between 2000 and 2050. At least half of these adults will die between 30 and 69 years of age, losing decades of productive life. Cancer and the total deaths due to smoking have fallen sharply in men in high-income countries but will rise globally unless current smokers, most of whom live in low- and middle-income countries, stop smoking before or during middle age. Tripling the taxes on tobacco could rapidly raise cessation rates and deter the initiation of smoking. Higher taxes, regulations on smoking and information for consumers could avoid at least 115 million smoking-associated deaths in the next few decades, including around 25 million cancer deaths.

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Figure 1: Projected numbers of deaths from tobacco smoking during the twenty-first century.
Figure 2: Trends in cigarette consumption and male lung cancer rates, 1920–2005.
Figure 3: Risk of death from lung cancer in smokers and ex-smokers.
Figure 4: Death rates in middle-age from cancer and non-communicable disease by region, 2001.
Figure 5: France: smoking, tax and lung cancer rates in young males, 1980–2004.
Figure 6: Smoking deaths avoided through tax increases and non-price interventions, 2000–2050.


  1. 1

    Jha, P. et al. in Disease Control Priorities in Developing Countries (eds Jamison, D. T. et al.) 869–886 (Oxford Univ. Press, New York, 1996).

  2. 2

    Ezzati, M. & Lopez, A. D. Regional, disease specific patterns of smoking-attributable mortality in 2000. Tob. Control 13, 388–395 (2004).

  3. 3

    Ezzati, M., Henley, S. J., Lopez, A. D. & Thun, M. J. Role of smoking in global and regional cancer epidemiology: current patterns and data needs. Int. J. Cancer 116, 963–971 (2005).

  4. 4

    World Health Organization. MPOWER: A Policy Package to Reverse the Tobacco Epidemic (WHO, Geneva, 2008).

  5. 5

    Peto, R. & Lopez, A. D. in Critical Issues in Global Health (eds Koop, E. C., Pearson, C. E. & Schwarz, M. R.) 154–162 (Jossey–Bass, New York, 2001).

  6. 6

    Peto, R., Lopez, A. D., Boreham, J. & Thun, M. Mortality from Smoking in Developed Countries, 1950–2005. University of Oxford Clinical Trial Service Unit [online], (2009).

  7. 7

    World Health Organization. Tobacco or Health: a Global Status Report (WHO, Geneva, 1997).

  8. 8

    International Agency for Research on Cancer. Tobacco smoke and involuntary smoking. IARC Monogr. Eval. Carcinog. Risks Chem. Hum. 83, 1–1438 (2004).

  9. 9

    United States Department of Health and Human Services. Reducing the Health Consequences of Smoking — 25 Years of Progress: a Report of the Surgeon General (US Department of Health and Human Services, Atlanta, 1989).

  10. 10

    International Agency for Research on Cancer. Smokeless tobacco and some tobacco-specific N-nitrosamines IARC Monogr. Eva. Carcinog. Risks Chem. Hum. 89, 1–592, (2007).

  11. 11

    United States Department of Health and Human Services. Reducing tobacco use: a report of the Surgeon General (US Department of Health and Human Services, Atlanta, 2000).

  12. 12

    United States Department of Health and Human Services. Health Consequences of Involuntary Exposure to Tobacco Smoke: a Report of the Surgeon General (US Department of Health and Human Services, Atlanta, 2006).

  13. 13

    Jha, P., Ranson, M. K., Nguyen, S. N. & Yach, D. Estimates of global and regional smoking prevalence in 1995, by age and sex. Am. J. Public Health 92, 1002–1006 (2002).

  14. 14

    Forey, B., Hamling, J. & Lee, P. International Smoking Statistics. A Collection of Historical Data from 30 Economically Developed Countries (Oxford Univ. Press, New York, 2009).

  15. 15

    Thankappan, K. R. & Mini, G. K. Case–control study of smoking and death in India. N. Engl. J. Med. 358, 2842–2843 (2008).

  16. 16

    Jha, P., Gupta, P. C. & Pandey, R. Case–control study of smoking and death in India. N. Engl. J. Med. 358, 2844–2845 (2008).

  17. 17

    Monteiro, C. A., Cavalcante, T. M., Moura, E. C., Claro, R. M. & Szwarcwald, C. L. Population-based evidence of a strong decline in the prevalence of smokers in Brazil (1989–2003). Bull. World Health Organ. 85, 527–534 (2007).

  18. 18

    Peto, R. et al. Smoking, smoking cessation, and lung cancer in the UK since 1950: combination of national statistics with two case–control studies. BMJ 321, 323–329 (2000). This study shows the benefits of cessation of smoking on the risk of lung cancer.

  19. 19

    Molarius, A. et al. Trends in cigarette smoking in 36 populations from the early 1980s to the mid-1990s: findings from the WHO MONICA Project. Am. J. Public Health 91, 206–212 (2001).

  20. 20

    Chinese Academy of Preventive Medicine. Smoking in China: 1996 National Prevalence Survey of Smoking Pattern (China Science and Technology Press, Beijing, 1997).

  21. 21

    Jenkins, C. N. et al. Tobacco use in Vietnam. Prevalence, predictors, and the role of the transnational tobacco corporations. JAMA 277, 1726–1731 (1997).

  22. 22

    Jha, P. et al. A nationally representative case–control study of smoking and death in India. N. Engl. J. Med. 358, 1137–1147 (2008). The first nationally representative study of smoking hazards in India.

  23. 23

    Office of the Registrar General of India. Sample Registration System: Baseline Survey Report 2004 (Registrar General of India, New Delhi, 2007).

  24. 24

    Martinson, B. C., O'Connor, P. J., Pronk, N. P. & Rolnick, S. J. Smoking cessation attempts in relation to prior health care charges: the effect of antecedent smoking-related symptoms? Am. J. Health Promot. 18, 125–132 (2003).

  25. 25

    International Agency for Research on Cancer. Tobacco control: reversal of risk after quitting smoking ( eds Dresler, C. & Leon, M. ) IARC Handbooks of Cancer Prevention. 11 (2007).

  26. 26

    Doll, R. & Peto, R. The causes of cancer: quantitative estimates of avoidable risks of cancer in the United States today. J. Natl Cancer Inst. 66, 1191–1308 (1981). A classic description of the avoidable mortality from cancer.

  27. 27

    Doll, R., Peto, R., Boreham, J. & Sutherland, I. Mortality in relation to smoking: 50 years' observations on male British doctors. BMJ 328, 1519 (2004). This report shows that the full effect of smoking throughout adult life is the loss of one decade of life expectancy.

  28. 28

    Doll, R., Peto, R., Wheatley, K., Gray, R. & Sutherland, I. Mortality in relation to smoking: 40 years' observations on male British doctors. BMJ 309, 901–911 (1994).

  29. 29

    Thun, M. J., Henley, S. J. & Calle, E. E. Tobacco use and cancer: an epidemiologic perspective for geneticists. Oncogene 21, 7307–7325 (2002).

  30. 30

    Peto, R., Lopez, A. D., Boreham, J., Thun, M. & Heath, C. Jr. Mortality from tobacco in developed countries: indirect estimation from national vital statistics. Lancet 339, 1268–1278 (1992). This study provides indirect estimates of the deaths due to smoking at a national level using a novel analytical method.

  31. 31

    Peto, R., Lopez, A. D., Boreham, J., Thun, M. & Heath, C. J. Mortality from Smoking in Developed Countries, 1950–2000 (Oxford Univ. Press, 1994).

  32. 32

    Lopez, A. et al. The Global Burden of Disease and Risk Factors (World Bank and Oxford Univ. Press, Washington DC and New York, 2006).

  33. 33

    Gu, D. et al. Mortality attributable to smoking in China. N. Engl. J. Med. 360, 150–159 (2009).

  34. 34

    Liu, B. Q. et al. Emerging tobacco hazards in China: 1. Retrospective proportional mortality study of one million deaths. BMJ 317, 1411–1422 (1998). The first nationally representative study of smoking hazards in China.

  35. 35

    Parkin, D. M. The global health burden of infection-associated cancers in the year 2002. Int. J. Cancer 118, 3030–3044 (2006).

  36. 36

    Chen, Z. M. et al. Smoking and liver cancer in China: case–control comparison of 36,000 liver cancer deaths vs. 17,000 cirrhosis deaths. Int. J. Cancer 107, 106–112 (2003).

  37. 37

    Plummer, M. et al. Smoking and cervical cancer: pooled analysis of the IARC multi-centric case–control study. Cancer Causes Control 14, 805–814 (2003).

  38. 38

    Jha, P., Mony, P., Moore, J. A. & Zatonski, W. Evidence-Based Cardiology (eds. Yusuf, S. et al.) 111–124 (Oxford Univ. Press, 2009).

  39. 39

    Teo, K. K. et al. Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART study: a case–control study. Lancet 368, 647–658 (2006).

  40. 40

    Smith, K. R. & Mehta, S. The burden of disease from indoor air pollution in developing countries: comparison of estimates. Int. J. Hyg. Environ. Health 206, 279–289 (2003).

  41. 41

    Doll, R. & Hill, A. B. Mortality in relation to smoking: ten years' observations of British doctors. BMJ 1, 1460–1467 (1964).

  42. 42

    Sitas, F. et al. Tobacco attributable deaths in South Africa. Tob. Control 13, 396–399 (2004).

  43. 43

    Ramin, B., Kam, D., Feleke, B., Jacob, B. & Jha, P. Smoking, HIV and non-fatal tuberculosis in an urban African population. Int. J. Tuberc. Lung Dis. 12, 695–697 (2008).

  44. 44

    Gajalakshmi, V., Peto, R., Kanaka, T. S. & Jha, P. Smoking and mortality from tuberculosis and other diseases in India: retrospective study of 43,000 adult male deaths and 35,000 controls. Lancet 362, 507–515 (2003). A large-scale study that showed the marked risks of tuberculosis death and infection from smoking.

  45. 45

    Gupta, P. C., Pednekar, M. S., Parkin, D. M. & Sankaranarayanan, R. Tobacco associated mortality in Mumbai (Bombay) India. Results of the Bombay Cohort Study. Int. J. Epidemiol. 34, 1395–1402 (2005).

  46. 46

    Bates, M. N. et al. Risk of tuberculosis from exposure to tobacco smoke: a systematic review and meta-analysis. Arch. Intern. Med. 167, 335–342 (2007).

  47. 47

    Lin, H. H., Ezzati, M. & Murray, M. Tobacco smoke, indoor air pollution and tuberculosis: a systematic review and meta-analysis. PLoS Med. 4, e20 (2007).

  48. 48

    Thun, M. J., Apicella, L. F. & Henley, S. J. Smoking vs other risk factors as the cause of smoking-attributable deaths: confounding in the courtroom. JAMA 284, 706–712 (2000).

  49. 49

    Niu, S. R. et al. Emerging tobacco hazards in China: 2. Early mortality results from a prospective study. BMJ 317, 1423–1424 (1998).

  50. 50

    Jha, P. et al. Social inequalities in male mortality, and in male mortality from smoking: indirect estimation from national death rates in England and Wales, Poland, and North America. Lancet 368, 367–370 (2006). This paper reported that half of the inequalities in mortality between rich, educated men and poor, uneducated men can be accounted for by smoking deaths.

  51. 51

    Gajalakshmi, C. K., Jha, P., Ranson, K. & Nguyen, S. N. in Tobacco Control in Developing Countries (eds Jha, P. & Chaloupka, F. J.) 11–39 (Oxford Univ. Press, 2000).

  52. 52

    Jha, P. & Chaloupka, F. J. Curbing the epidemic: governments and the economics of tobacco control (The World Bank, Washington DC, 1999). The economics of tobacco — explained simply.

  53. 53

    Hill, C. & Laplanche, A. Le tabac en France les vrais chiffres (La Documentation Française, Paris, 2003).

  54. 54

    Harris, J. E., Thun, M. J., Mondul, A. M. & Calle, E. E. Cigarette tar yields in relation to mortality from lung cancer in the cancer prevention study II prospective cohort, 1982–1988. BMJ 328, 72 (2004).

  55. 55

    Jha, P. & Chaloupka, F. J. Tobacco Control in Developing Countries (Oxford Univ. Press, 2000).

  56. 56

    Chaloupka, F. J., Tauras, J. A. & Grossman, M. in Tobacco Control in Developing Countries (eds Jha, P. & Chaloupka, F. J.) 107–129 (Oxford Univ. Press, 2000).

  57. 57

    Chaloupka, F. J. & Warner, K. E. in The Handbook of Health Economics (eds Newhouse, J. & Culyer, A.) 1539–1627 (Elsevier, Amsterdam, 2000).

  58. 58

    Chaloupka, F. J., Hu, T. W., Warner, K. E., Jacobs, R. & Yurekli, A. in Tobacco Control in Developing Countries (eds Jha, P. & Chaloupka, F. J.) 237–272 (Oxford Univ. Press, 2000).

  59. 59

    Van Walbeek, C. Tobacco control in South Africa. Promot. Educ. (Suppl. 4), 25–28 (2005).

  60. 60

    Wasserman, J., Manning, W. G., Newhouse, J. P. & Winkler, J. D. The effects of excise taxes and regulations on cigarette smoking. J. Health Econ. 10, 43–64 (1991).

  61. 61

    Tauras, J. A. & Chaloupka, F. J. Impact of tobacco control spending and tobacco control policies on adolescents' attitudes and beliefs about cigarette smoking. Evid. Based Prev. Med. 1, 111–120 (2004).

  62. 62

    Tauras, J. A. The transition to smoking cessation: evidence from multiple failure duration analysis. NBER Working Paper No. 7412 (National Bureau of Economic Research, Cambridge, 1999).

  63. 63

    Emery, S., White, M. M. & Pierce, J. P. Does cigarette price influence adolescent experimentation? J. Health Econ. 20, 261–270 (2001).

  64. 64

    Chaloupka, F. J. Rational addictive behaviour and cigarette smoking. J. Political Econ. 99, 722–742 (1991).

  65. 65

    Centers for Disease Control and Prevention (CDC). Response to increases in cigarette prices by race/ethnicity, income, and age groups —United States, 1976–1993. Morb. Mortal Wkly Rep. 47, 605–609 (1998).

  66. 66

    Townsend, J. L., Roderick, P. & Cooper, J. Cigarette smoking by socio-economic group, sex, and age: effects of price, income, and health publicity. BMJ 309, 923–926 (1998).

  67. 67

    Guindon, E. & Bettcher, D. Tobacco control in tobacco-producing countries. Bull. World Health Organ. 79, 1086 (2001).

  68. 68

    Blecher, E. H. & van Walbeek, C. P. An international analysis of cigarette affordability. Tob. Control 13, 339–346 (2004).

  69. 69

    Mayosi, B. M. et al. The burden of non-communicable diseases in South Africa. Lancet (in the press).

  70. 70

    Ciecierski, C. in 12th World Conference on Tobacco or Health: Global Action for a Tobacco Free Future (2003).

  71. 71

    Weinstein, N. D. Accuracy of smokers' risk perceptions. Ann. Behav. Med. 20, 135–140 (1998).

  72. 72

    Kenkel, D. & Chen, L. in Tobacco Control in Developing Countries (eds Jha, P. & Chaloupka, F. J.) 177–214 (Oxford Univ. Press, 2000).

  73. 73

    United Kingdom Medical Research Council. Smoking and Health: Summary and Report of the Royal College of Physicians of London on Smoking in relation to Cancer of the Lung and other Diseases (UK Medical Research Council, London, 1962).

  74. 74

    United States Department of Health, Education & Welfare. Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service (US Department of Health, Education, and Welfare, Atlanta, 1964).

  75. 75

    Townsend, J. Policies to halve smoking deaths. Addiction 88, 37–46 (1993).

  76. 76

    Hammond, D., Fong, G. T., McNeill, A., Borland, R. & Cummings, K. M. Effectiveness of cigarette warning labels in informing smokers about the risks of smoking: findings from the International Tobacco Control (ITC) Four Country Survey. Tob. Control 15 (Suppl. 3), iii19–iii25 (2006).

  77. 77

    Bauer, J. E., Hyland, A., Li, Q., Steger, C. & Cummings, K. M. A longitudinal assessment of the impact of smoke-free worksite policies on tobacco use. Am. J. Public Health 95, 1024–1029 (2005).

  78. 78

    Fichtenberg, C. M. & Glantz, S. A. Effect of smoke-free workplaces on smoking behaviour: systematic review. BMJ 325, 188 (2002).

  79. 79

    McNabola, A. & Gill, L. W. The control of environmental tobacco smoke: a policy review. Int. J. Environ. Res. Public Health 6, 741–758 (2009).

  80. 80

    Levy, D. T., Friend, K. & Polishchuk, E. Effect of clean indoor air laws on smokers: the clean air module of the SimSmoke computer simulation model. Tob. Control 10, 345–351 (2001).

  81. 81

    Jacobson, P. D. & Wasserman, J. Tobacco Control Laws: Implementation and Enforcement (RAND, Santa Monica, 1997).

  82. 82

    Federal Trade Commission. Cigarette report for 2004 and 2005 (Federal Trade Commission, Washington DC, 2007).

  83. 83

    Saffer, H. & Chaloupka, F. J. Tobacco advertising: economic theory and international evidence. J. Health Econ. 19, 1117–1137 (2000).

  84. 84

    Blecher, E. The impact of tobacco advertising bans on consumption in developing countries. J. Health Econ. 27, 930–942 (2008).

  85. 85

    United States Department of Health and Human Services. The Health Consequences of Smoking: Nicotine Addiction: a Report of the Surgeon General (eds Davis, R. M., Novotny, T. E. & Lynn, W. R.) (US Department of Health and Human Services, Atlanta,1988).

  86. 86

    Eisenberg, M. J. et al. Pharmacotherapies for smoking cessation: a meta-analysis of randomized controlled trials. CMAJ 179, 135–144 (2008).

  87. 87

    Stead, L. F., Perera, R., Bullen, C., Mant, D., & Lancaster, T. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst. Rev. 1, CD000146 (2008).

  88. 88

    Merriman, D., Yurekli, A. & Chaloupka, F. J. in Tobacco Control in Developing Countries (eds Jha, P. & Chaloupka, F. J.) 365–392 (Oxford Univ. Press, 2000).

  89. 89

    Joossens, L., Chaloupka, F. J., Merriman, D. & Yurekli, A. in Tobacco Control in Developing Countries (eds Jha, P. & Chaloupka, F. J.) 393–406 (Oxford Univ. Press, 2000).

  90. 90

    Joossens, L. & Raw, M. Turning off the tap: the real solution to cigarette smuggling. Int. J. Tuberc. Lung Dis. 7, 214–222 (2003).

  91. 91

    Joossens, L. & Raw, M. Progress in combating cigarette smuggling: controlling the supply chain. Tob. Control 17, 399–404 (2008).

  92. 92

    Warren, C. W., Jones, N. R., Eriksen, M. P. & Asma, S. Patterns of global tobacco use in young people and implications for future chronic disease burden in adults. Lancet 367, 749–753 (2006).

  93. 93

    Mathers, C. D. & Loncar, D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 3, e442 (2006).

  94. 94

    Corti, C. A History of Smoking (Bracken Books, London, 1996).

  95. 95

    Zatonski, W. & Jha, P. The Health Transformation in Eastern Europe After 1990: a Second Look (Marie Skeodowska-Curie Cancer Center and Institute of Oncology, Warsaw, 2000).

  96. 96

    Crispo, A. et al. The cumulative risk of lung cancer among current, ex- and never-smokers in European men. Br. J. Cancer 91, 1280–1286 (2004).

  97. 97

    Thun, M. J. et al. Lung cancer occurrence in never-smokers: an analysis of 13 cohorts and 22 cancer registry studies. PLoS Med. 5, e185 (2008).

  98. 98

    Sun, S., Schiller, J. H. & Gazdar, A. F. Lung cancer in never smokers — a different disease. Nature Rev. Cancer 7, 778–790 (2007).

  99. 99

    World Bank. World Development Indicators 2006 (World Bank, Washington DC, 2006).

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I thank F. J. Chaloupka for helpful comments, J. Boreham, M. Ezzati, C. Hill, R. Peto and M. Thun for providing access to various mortality data and smoking estimates, L. Aleksandrowicz for help with graphics and O. P. Malhotra and L. Corson for editing support. The author is supported by the Fogarty International Centre (grant R01 TW007939-01), the Li Ka Shing Knowledge Institute and Keenan Research Centre, St. Michael's Hospital and the Canada Research Chair programme.

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Jha, P. Avoidable global cancer deaths and total deaths from smoking. Nat Rev Cancer 9, 655–664 (2009) doi:10.1038/nrc2703

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