A man lights a cigarette in Old Delhi, India.
A man lights a cigarette in Old Delhi, India. Anindito Mukherjee/Reuters

The Tobacco Atlas shows how even non-smokers feel the public health impacts of the industry.

In 2015, tuberculosis overtook HIV as the leading cause of death from infectious disease in the world. In South Africa, for example, 780 people are infected with TB for every 100,000 people. In the U.S., the number is 2.9, though last year, the number of tuberculosis cases in New York City jumped by 10 percent—the largest increase since 1992.

According to Neil Schluger, a senior advisor for science and education at Vital Strategies, there’s a somewhat surprising reason why the bacterial disease remains such a formidable killer around the world: tobacco use.

“I think it’s an important connection to make because we don’t often think of things like tobacco as being related to infectious diseases,” said Schluger. “Smokers have a much higher risk of developing the active form [of TB].”

Between 1.7 and 2 billion people worldwide have been exposed to TB, and carry it in its latent form, but only about 10 percent ever go on to get the active disease. It’s often contracted after coming into contact with someone who is actively infected, and smoking damages your immune system, making it easier to develop the active infection. It also increases the likelihood that antibiotics will fail, or later, that a previously infected patient will relapse. “At every step,” Schluger said, “tobacco makes it worse.”

This is one of the takeaways of sixth edition of The Tobacco Atlas, a multimedia publication from the public health nonprofit Vital Strategies that focuses on tobacco control issues. The document provides resources on the whole chain of tobacco use, from production and marketing to addiction, quitting, and associated health issues. Schluger believes that tobacco use is the leading single preventable cause of death in the world—not just because of the types of diseases we traditionally associate with it, such as lung cancer or emphysema, but because of the way it can help spread other infectious diseases, too. He estimates that TB rates, for example, would drop an estimated 20 percent worldwide if tobacco use was eliminated.

The world map below gives a sense of the issue by displaying the number of TB deaths in each country that are attributable to tobacco. Darker pink correlates with a higher percentage of these tobacco-spurred TB deaths, while lighter pink represents lower percentages.

Hovering over the map, it is immediately apparent that Russia, as well as many Asian countries, have the highest number of TB deaths that are thought to be caused by tobacco—in Russia, 19.6 percent of tuberculosis deaths in 2017 were caused by tobacco, and in China, the number is 14.4 percent. This is also the region with the highest TB rates in the world: 40 to 45 percent of all TB cases come from India, China, and Indonesia, Schluger says.

Many African countries are a lighter pink color on this map, even though TB rates alone are very high there—that’s at least partly because fewer people in those countries smoke. “At the moment there are only 77 million people in Africa who smoke, out of about 1.1 billion Africans,” Schluger said.

The map below, from the World Health Organization’s 2017 Global Tuberculosis Report, shows this: When removing tobacco from the equation, the estimated TB incidence rates per 100,000 people in each country in 2016 are the highest in Africa. If tobacco companies start moving into these markets more aggressively, “it will just be like throwing gasoline on the TB fire there.”

Global Tuberculosis Report 2017 (World Health Organization)

With smoking rates in the U.S. falling for over a decade, tobacco companies have indeed been seeking profits in emerging markets—including war zones in unstable countries, as a recent Guardian series reported. Schluger thinks that the main reason this market penetration hasn’t happened yet, at least in Africa, is because the continent has historically been so poor. But last year, Japan Tobacco Inc.—the fourth-largest tobacco company in the world—became the majority shareholder in Ethiopia’s tobacco share company. “Ethiopia has 105 million people—it’s the second-largest country in Africa, and it has a growing economy,” Schluger said. “So the tobacco companies say ‘here’s an emerging market for us.’”

That has big public health implications, especially in a region that’s already afflicted by so many challenges from infectious diseases. “Tobacco’s effects go far beyond the people who use it directly, because tobacco makes it more likely that you’re going to have the infectious disease,” Schluger said. “Once you have that, you’re going to spread it to other people who never smoke.”

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