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Smoking prevalence and mortality in Spain
Prevalencia y mortalidad por tabaco en España
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During the past 50 years, generations of men and women who started smoking in adolescence and continued to smoke until middle and advanced age have had to pay a high price, so that their relative risk for all-cause mortality has increased. Since the 60s the age-adjusted relative risk in regular smokers compared to non-smokers is more than twice in men and over three times in women. Smokers shorten their life expectancy by more than 10 years on average for their excess risk to suffer from over 30 diseases associated with tobacco use, and sometimes they die from common health problems due to complications from surgery or pneumonia.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> People should stop smoking completely as soon as possible. Quitting smoking at age 40 reduces the potential years of life lost by 90%, stopping at age 60 reduces the risk of death by 40%. But simply reducing the number of cigarettes smoked daily has no significant impact on mortality, among other things, because the pattern of consumption tends to compensate for the inhalation of toxic fumes when the number of cigarettes is decreased.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">One of the best papers published in recent years analyzes the stages of the smoking epidemics on a theoretical model of 100 years (20th century) in which several stages can be seen in the evolution of tobacco prevalence and mortality.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> In developed countries, the smoking prevalence is clearly declining in both sexes. In the past 20 years, the contribution of deaths from smoking to overall mortality has decreased in men and in women it continues to increase in Spain. However, this has already been stabilized in other countries. Although the rate of deaths in individuals aged 35–69 attributable to smoking is generally higher in men than in women, it tends to converge in some developed countries. The explanation appears to be that women were massively incorporated to smoking 2 decades before, compared to Spain. For this reason, and because the interval between the peak prevalence of smoking, and the peak of mortality from lung cancer is 3 decades, countries like USA, UK or Australia have already reached a point where the number of deaths from lung cancer is about the same in both sexes, bearing in mind that in the 80s prevalence levels were alike.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Projections for 2025 suggest that smoking prevalence and attributable mortality will drop in parallel in many developed countries. The model appears to be applicable to men, but it is unclear to what extent young women will continue starting smoking in new waves. In accordance with this model, Spain would be in the transition from phase 3 to phase 4, while the most advanced countries are already in phase 4. Phase 3 is characterized by a decreased prevalence in both sexes (more pronounced in males) while mortality tends to be stabilized in men and dramatically increased in women. At this stage, smoking-attributable mortality ranges from 10 to 30% of all deaths (15.2% in Spain in 2012, being 22.6% in men and 7.6% in women). In stage 4, the percentage of smoking-attributable deaths in men can reach up to 1/3 of the total and somewhat less in women. In a recent study on the population of Georgia (USA) it has been estimated that mortality from lung cancer in women will begin to decrease from 2020 on.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> However, in other countries like South Korea, in full phase 3 of the epidemic, mortality from lung cancer has been stabilized in men, but begins to increase in women by 1.5% rate annually. This indicates that it will not begin to decrease in Korean women before 30 years’ time.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> It is interesting to compare mortality data of the article in this issue of Clinical Medicine “Impact of tobacco use on mortality in Spain in 2012”<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> with those of 2006.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> According to these studies, the prevalence of smoking (daily smokers) in males dropped by almost 1% per year from 2006 to 2012, while in women it dropped by 0.5% annually. During this period, mortality from lung cancer attributable to tobacco remains stable, while the number of deaths in women is multiplied by two. The point of convergence will depend on the mortality rate decline in men. In the case of men that peak prevalence occurred around the year 1975, but in women it was in 1995. This indicates that mortality in males has been stabilized or has been dropping since 2005. However, in women this will not happen until 2025 or later. Until then, female lung will cancer will not stop increasing because it will not depend on the current control measures but on those which should have been adopted in the past.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Despite the magnitude of the figures, the overall smoking-attributable mortality might have been underestimated. Some recent papers estimate this percentage by 17%. If we accept this hypothesis, the overall mortality in Spain would be 70,000 deaths per year.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> Mortality studies will still be needed to verify trends and see if the prevalence decline remains after the reduction in mortality from various causes. Mortality statistics are of little use in planning health resources. However, chronic morbidity statistics would be helpful to provide sufficient resources for their care. A problem with this paper is that it cannot be compared to previous Spanish studies since they do not use exactly the same methodology.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> The highest number of attributable deaths reported in the study in males compared to 2006, may be influenced by population aging. Nevertheless, in both cases the overall mortality would had been approximately 60,000 deaths. Finally, the most important issue is to implement all measures to prevent children and women from starting smoking. In this regard, increased tobacco taxes, access to treatments for addiction and the adoption of measures to reduce the attractiveness of the product, such as the “Plain packaging” can be crucial to prevent future peaks in smoking mortality, particularly in women. In Australia, the first country to introduce this measure, the prevalence has dropped by 15% in 2 years.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> In Spain, we will continue to observe in the next 2 decades a gradual decline in smoking prevalence in both sexes, until reaching convergence in the overall population as it already occurs in people aged under 25. Smoking mortality in men will tend to decline, while dramatic rise in women, rates doubling every 5 or 6 years to reach convergence with men. Current or future mortality is a good long-term indicator of the effectiveness of prevalence control measures adopted in the past. The extent of implementation of effective control measures both in population and individually will determine the price in lives lost each year by the tobacco epidemic.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Córdoba García R. Prevalencia y mortalidad por tabaco en España. Med Clin (Barc). 2015;145:532–533.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The health consequences of smoking-50 years of progress: a report of the surgeon general" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "U.S. Department of Health and Human Services" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2014" "editorial" => "U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health" "editorialLocalizacion" => "Atlanta, GA" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0065" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Is there a health benefit of reduced tobacco consumption? 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