The study, “,” was published January 8 in the Journal of the American Medical Association in a special issue devoted to tobacco.

Overall, age-standardized smoking prevalence decreased by 42% for women and 25% for men between 1980 and 2012. Four countries—Canada, Iceland, Mexico, and Norway—have reduced smoking by more than half in both men and women since 1980.

But substantial population growth between 1980 and 2012 contributed to a 41% increase in the number of male daily smokers and a 7% increase for females. In 2012, smoking prevalence among men was higher than for women in all countries except Sweden. More than 50% of men smoke every day in several countries, including Russia, Indonesia, Armenia, and Timor Leste. Smoking prevalence for women was above 25% in Austria, Chile, and France and higher than 30% in Greece, among the highest percentages in the world. The lowest smoking rates for men can be found in Antigua and Barbuda, Sao Tome and Principe, and Nigeria. For women, smoking rates are lowest in Eritrea, Cameroon, and Morocco.

These differences persist despite decades of strong tobacco control measures globally. Fifty years ago, the first U.S. Surgeon General’s report was issued on the health impact of smoking, The report spurred research on tobacco and investments by governments and nonprofit agencies to reduce tobacco prevalence and cigarette consumption. In 2003, the Framework Convention on Tobacco Control was adopted by the World Health Assembly and has since been ratified by 177 countries.

“Despite the tremendous progress made on tobacco control, much more remains to be done,” said Dr. Christopher Murray, UW professor of global health and director of the Institute for Health Metrics and Evaluation. “We have the legal means to support tobacco control. Where we see progress being made we need to look for ways to accelerate that progress. Where we see stagnation, we need to find out what’s going wrong.”

According to the most recent figures from the , coordinated by the Institute for Health Metrics and Evaluation, tobacco use led to 5.7 million deaths, 6.9% of years of life lost, and 5.5% of total health loss around the world. These estimates exclude health effects from secondhand smoke.

The Institute based its estimates on a wide range of data sources, including in-country surveys, government statistics, and World Health Organization data. Previous estimates typically have used fewer data sources.

The greatest health risks for both men and women are likely to occur in countries where smoking is pervasive and where smokers consume a large quantity of cigarettes. These countries include China, Ireland, Italy, Japan, Kuwait, South Korea, the Philippines, Uruguay, Switzerland, and several countries in Eastern Europe. The number of cigarettes smoked around the world has grown to more than 6 trillion. In 75 countries, smokers consumed an average of more than 20 cigarettes per day in 2012.

“Tobacco control is particularly urgent in countries where the number of smokers is increasing,” said Alan Lopez, Laureate Professor at the University of Melbourne. “Because we know that half of all smokers will eventually be killed by tobacco, greater numbers of smokers will mean a massive increase in premature deaths in our lifetime.”

There have been three phases of global progress in reducing the age-standardized prevalence of smokers: modest progress from 1980 to 1996, followed by a decade of more rapid global progress, then a slowdown in reductions from 2006 to 2012. This was in part due to increases in the number of smokers since 2006 in several large countries, including Bangladesh, China, Indonesia, and Russia.

Annualized rate of change captures the relative reduction in smoking prevalence, and several countries had notable declines of 2% or more between 1980 and 2012. For men, annualized rates of decline of 2% or more occurred in 17 countries, with the greatest rates of decline observed in Canada, Iceland, Mexico, Norway, and Sweden. For women, annualized rates of decline greater than 2% were achieved in 22 countries. Bolivia, Canada, Denmark, Iceland, Israel, Norway, Sweden, and the United States all had prevalence rates in 1980 higher than 20%, but achieved annualized rates of decline of greater than 2%. In a disturbing trend, Austria, Bulgaria, and Greece all had prevalence rates greater than 20% in 1980 and have shown statistically significant increases since then.

“Change in tobacco prevalence typically has been slow, underscoring what a hard habit it is to break,” said Emmanuela Gakidou,UW professor of global health and director of education and training at the Institute for Health Metrics and Evaluation. “But we know from these global trends that rapid progress is possible. If more countries were able to repeat the success we have seen in Norway, Mexico, and the United States, we would see much less health loss from smoking.”

Which countries had the highest and lowest smoking prevalence for men in 2012?

Which countries had the highest and lowest smoking prevalence for women in 2012?

Which countries where smoking prevalence was greater than 20% in 1980 had the fastest declines and the biggest annual increases between 1980 and 2012?

In terms of number of cigarettes, which countries with populations greater than 1 million had the highest and lowest average consumption per smoker per day in 2012?

“Globally, there has been significant progress in combating the deadly toll of tobacco use,” said Matthew L. Myers, president of the Campaign for Tobacco-Free Kids in response to the paper. “These findings demonstrate both that where countries take strong action, tobacco use can be dramatically reduced and the devastating consequences when countries do not fully adopt and implement effective tobacco control measures.”

Download the JAMA  article: 

Download the JAMA supplement: 

An online visualization tool showing data for each country is available at:

Watch a training tutorial of the visualization tool at: 

“In other words, people are as likely to smoke whether or not they were sexually or physically abused, but they’re inclined to smoke more if they were abused and have a history of smoking,” said , a professor in the UW School of Social Work.

The paper is published online in the .

Herrenkohl and co-authors probed the Lehigh Longitudinal Study, which began in the mid-1970s. Participants were recruited from child welfare abuse and protective service programs, as well as day care programs, private nursery programs and Head Start classrooms in Eastern Pennsylvania.

UW researchers looked specifically for any connection between physical or sexual abuse and adolescent and adult smoking. They found that boys who had experienced either type of abuse and were smokers, smoked more than those who hadn’t been abused as a child. For girls who smoked, only those who had been sexually abused smoked more as adolescents. That frequency of adolescent smoking by both girls and boys, in turn, led to increased smoking in adulthood, especially among women.

Lead author , a doctoral candidate in social work, found the difference between boys and girls to be one that requires more study.

“There may be other factors at work that we need to disentangle,” she said. “I think the big ‘Aha’ finding is the one on gender differences. Hopefully this will encourage other researchers to look at gender differences in smoking among teens and adults.”

In the Lehigh study, slightly more than 50 percent of the participants said they had smoked in adolescence – that’s about five times the national average for children ages 12-17. Fifty-seven percent of males and 44 percent of females reported smoking in adolescence. Researchers said they don’t know why the rate of smoking was so high in this study. Herrenkohl theorizes that the reasons could have been socioeconomic, geographical, or the fact that participants in this study were already at relatively high risk.

When study participants were evaluated as adults, 49 percent reported smoking in the past year (at nearly equal rates for men and women).

Kristman-Valente said what is of great concern is the fact that so many women who were abused as children were smoking while raising children, and that women who smoke frequently also are less successful in smoking cessation programs.

Since tobacco use often begins in adolescence, researchers say it’s important that public policies are in place to try to prevent kids from lighting up a cigarette in the first place.

“Early adversity can persist throughout a person’s life, so early intervention or prevention of child abuse can potentially lead to long-term public health benefits,” Kristman-Valente said. “I hope our findings encourage more focus on the connection between child maltreatment and smoking in particular. Not many people look at this consequence, even though smoking is the number one cause of preventable death in the U.S.”

The other co-author is , a UW research assistant professor in social work. The research was funded by the , , the , and the .

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For more information, contact Kristman-Valente at ankv@uw.edu, or Herrenkohl at 206-221-7873 or tih@uw.edu.