Models of smoking-attributable mortality must consider the effects of major intervention - Foundation for a Smoke-Free World

Models of smoking-attributable mortality must consider the effects of major intervention

When I studied epidemiology in the 1980s, Apartheid policies were still in effect in my home country, South Africa. At the time, many in the field believed that their roles transcended the narrow confines of epidemiology’s standard definition. That is, we wanted to do more than simply describe race, class and sex-based differences across metrics of death and disease. We viewed such measurements as a necessary first step toward addressing the factors underlying these differences, with the ultimate goal of improving health. We defined an epidemiologist as someone who studies the determinants of death and disease in order to take actions to improve health and reduce inequalities.

The brief phrase, “in order to take action,” has driven my work and that of so many colleagues who seek to improve global health. Such a clause shifts epidemiology from being a set of methods to help explain the world, to being a means of defining how to make the world a better place. Unfortunately, not all epidemiologists subscribe to this definition. In the field of tobacco control, in particular, there appears to be a disturbing acceptance of the status quo. Too many of my colleague are resigned to business as usual, not daring to explore actions that could improve the world.

Exemplifying this approach, a recent article by Janssen et al provides “novel forecasting enabled realistic estimates of the mortality imprint of the smoking epidemic in Europe up to 2100.” Which is to say: they summarize techniques that might help us estimate deaths from smoking 80 years from now. The authors assert that their “projected levels can be used as a baseline to assess the influence of future specific public health action.” Yet, they fail to identify—or even consider—what those public health actions might be. Void of ambition or action, the paper projects a future of static policy and therefore minimal health gains.

Janssen and colleagues indeed miss an opportunity to identify factors that could very well reverse discouraging trends in smoking mortality. There is no mention, for example, of current advances in tobacco harm reduction (THR), which have the potential to cut future death rates substantially. Similarly, they fail to acknowledge ongoing breakthroughs in cancer screening, as well as emerging treatments that will cut death rates of major tobacco attribute diseases (e.g., lung and oral cancer). Finally, the authors fail to mention the rapid advances underway that should yield tools with one year quit rates 10 to 50% higher than currently available products.

Such advances do not reflect wishful thinking. They are genuine innovations that could radically alter the projections Janssen outlines. In a recent article, I offered indicative data on this and showed that smoking-related mortality in 2060 could be cut by about 3.5 million deaths if we: (1) increase access to THR products; and (2) improve treatment, cessation, and diagnostic tools. 

Models should do more illustrate the inadequacy of current polices. They should inspire action to improve upon the status quo. As the world grapples with COVID-19, this lesson is being reinforced daily. It is not good enough to provide data on how many people will become infected and die. We must also consider the counterfactual: how many lives can we save through better policies. This type of thinking—the “in order to take action” stance—inspires real change.

Toxic tobacco products kill 8 million people each year. We must raise our ambition and provide the data and guidance needed to finally bring an end to this epidemic.


I would have preferred to publish this response in Tobacco Control, in order to stimulate needed debate. However, the journal bans submissions from authors funded in any way by the tobacco industry. This policy severely limits debate at a time when we should welcome all with solutions to be at the table. A recent publication examining better models for smoking and its impacts is a welcome example of how collaborative research—involving tobacco industry and leading academic researchers—can lead to new and needed insights.

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