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1.
Introduction
The
epidemic
of
tobacco-related
diseases
is
the
first
worldwide epidemic created by humans. Tobacco use killed
100 million people globally
in
the 20th century and will kill
1
billion
in
the
21st
century
if
current
patterns
persist
[1,2].
Tobacco
use
is
also
a
burden
on
global
economic
development.
In
the
United
States
alone,
the
estimated
economic
cost
related
to
tobacco
consumption
is
$289
billion
per
year
[3] .Tobacco
use
is
a
known
risk
factor
of
cancer
and
other
diseases
in
a
number
of
organs.
Although
tobacco
use
has
some
short-term
health
effects,
tobacco-related mortality
usually
peaks
a
few
decades
after
smoking
[4].
Therefore,
knowing
patterns
of
tobacco
smoking
not
only
helps
to
understand
the
current
epidemiology
of
smoking-related
diseases
but
also
can
provide
valuable
information
about
the
epidemiology
of
these
diseases
in
the
future.
In this review, we provide
information on prevalence and
trends of
tobacco
smoking at global and
regional
levels. We
also
briefly
review
the
use
of
electronic
cigarettes
(e-
cigarettes),
which
has
been
rapidly
growing.
Finally,
we
discuss
legislative
and
regulatory
efforts
around
tobacco
control
and
their
effects
on
smoking
patterns.
2.
Evidence
acquisition
We
used
several
sources
of
smoking
data
to
present
the
most
up-to-date
information
from
national
surveys.
For
current
regular
smoking, we used
the Global Adult Tobacco
Survey
(GATS),
an
international
survey
using
the
same
protocol
across
the
surveys,
as
the main
source
of
national
data
[5]. When data
for specific countries were not available
from
this
survey, we
used
the World Health
Organization
(WHO)
Report
on
the Global
Tobacco
Epidemic
2013
(also
known as
the Global Tobacco Control Report
[GTCR]), which
collected
data
(up
to
2012)
from
various
sources
[6]. We
also
used
a
subnational
survey
[7]and
a
few
national
surveys
[8–16]for more
recent
smoking data
that were not
included
in GATS or
the GTCR, as well as
for
information on
e-cigarettes
[8,17–23] .For daily
smoking data, we used
the
estimated
prevalence
presented
in
a
publication
from
the
Institute
for
Health Metrics
and
Evaluation
(University
of
Washington,
Seattle, WA,
USA)
[24].
Although
the
main
focus of
this
review
is
smoking
in adults, we used data
from
the
Global
Youth
Tobacco
Survey,
an
international
survey
on youth
tobacco use
[5,25],
to
show data on youth
tobacco
use. We
also
briefly
discuss
smokeless
tobacco
use
even
though
its
associations with
urologic
diseases
are
not well
established, because
it
is
the most common
form of
tobacco
use
in
certain
countries.
Throughout
this
article,
tobacco
smoking
refers
to
smoking
of
any
tobacco
product
(cigarette,
cigar,
cigarillo,
hookah, bidi, or any other product), unless stated otherwise.
To
combine
data
and
show
trends
of
smoking
prevalence
from 1980
to 2012 and
current
coverage of
tobacco policies
by
continents,
we
used
the
United
Nations
(UN)
list
of
countries
in each continent
[26]. This
list
is slightly different
from
some
commonly
used
lists:
Armenia,
Azerbaijan,
Cyprus,
Georgia,
and
Turkey
are
considered
West
Asian
rather
than European
countries. Nevertheless, we used
this
official
UN
list,
and
this
difference
did
not
substantially
change
the
trends/coverages
in
continents.
The
only
exception
to
using
the
UN
list
was
when
we
showed
smoking
rates
for
individual
countries.
From
the
above
West
Asian
countries
in
the
UN
list,
smoking
rates
were
shown
for
Cyprus
and
Turkey,
both
of
which
are
listed
among
European
countries
in
Table 1. We
used
the World
Bank databases
to obtain countries’ populations and
income
groups
[27] .Income
groups were
defined
by
annual
gross
national
income
per
capita
as
low,
$1045;
lower middle,
$1046–$4125;
upper
middle,
$4126–$12
745;
and
high,
$12
746.
3.
Evidence
synthesis
3.1.
Global
patterns
of
tobacco
smoking
Recent estimates suggest
that
in 2012, 928 million men and
207 million women were
current
smokers
of
any
tobacco
product
globally
[28] ,and
the majority
(807 million men
and
160 million
women)
were
daily
smokers
[24] .Most
countries with
the highest male
smoking prevalence
are
in
East
Asia,
Southeast
Asia,
and
Eastern
Europe.
The
highest
female
smoking
rates
are mostly
in
European
countries.
3.1.1.
Tobacco
epidemic
Trends
in
smoking
prevalence
in
most
high-income
countries have
followed a pattern
that
is commonly
termed
the
tobacco
epidemic
or
the
cigarette
epidemic
[4,29].
In
this
model,
smoking
prevalence
first
increases
among
men,
followed by an
increase
in women. Smoking-related
cancer
mortality
starts
to
increase
substantially
after
approxi-
mately
three
to
five
decades
( Fig. 1 ) [4,30].
The
estimated
age-standardized
smoking
prevalence
in
men
and
women
has
been
decreasing
on
all
continents
( Fig. 2). From 1980
to 2012,
smoking
rates
in both men and
women
substantially
decreased
in Oceania
and
the
Amer-
icas,
chiefly
in New
Zealand, Australia,
and North America.
In
Europe,
although male
smoking
has
also
substantially
decreased,
female
smoking
has
started
to
show
a modest
decrease
only
recently.
In
Asia, male
smoking
rates were
increasing
in
the 1980s
and
started
to decrease
in
the mid-
1990s;
nevertheless,
the
smoking
prevalence
in men was
>
35%
in
2012,
the
highest
of
all
continents.
The
smoking
prevalence
in African men has been
lower
than
that of men
in
other
continents.
Smoking
by women
in Africa
and Asia
has
been
traditionally
low
(chiefly
<
5%)
and
changed
little
from
1980
to
2012.
As
male
smoking
in
many
African
countries
and
female
smoking
in many
low-
and middle-
income countries
(LMICs) have not yet
followed
the
tobacco
epidemic
pattern,
a major
priority
for health
authorities
in
LMICs must be to prevent a surge
in smoking similar to what
happened
in
high-income
countries.
3.1.2.
Duration
and
intensity
of
smoking
Increased
harm
from
smoking
is
associated
with
longer
duration of
smoking, higher
smoking
intensity
(the average
E U R O P E A N
U R O L O G Y
F O C U S
1
( 2 0 1 5
)
3 – 1 6
4