Article Text

Stages of the cigarette epidemic on entering its second century
  1. Michael Thun1,2,
  2. Richard Peto3,
  3. Jillian Boreham3,
  4. Alan D Lopez2
  1. 1Epidemiology and Surveillance Research, American Cancer Society, Atlanta, Georgia, USA
  2. 2School of Population Health, University of Queensland, Brisbane, Australia
  3. 3Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), University of Oxford, Oxford, UK
  1. Correspondence to Dr Michael Thun, Vice President Emeritus, Epidemiology and Surveillance Research, American Cancer Society, Atlanta, GA 30303, USA; michael.thun{at}


Objectives A four-stage model of the cigarette epidemic was proposed in 1994 to communicate the long delay between the widespread uptake of cigarette smoking and its full effects on mortality, as had been experienced in economically developed countries where cigarette smoking became entrenched decades earlier in men than in women. In the present work, the question of whether qualitative predictions from the model have matched recent trends in smoking and deaths from smoking in countries at various levels of economic development is assessed, and possible projections to the year 2025 are considered.

Methods The proportion of all deaths attributed to tobacco was estimated indirectly for 41 high-resource and medium-resource countries from 1950 to the most recent year for which data were available, generally about 2005–2009. The trends in tobacco-attributed mortality in later middle age were then projected forward to 2025, based on recent trends in tobacco-attributed mortality in early middle age.

Results In developed countries the prevalence of smoking has continued to decrease in both sexes, although the rate of decrease has slowed and is less than that predicted by the original version of the model. Over the past 20 years the proportionate contribution of smoking to all deaths has decreased in men while continuing to increase or plateau among women. Although the proportion of all deaths at ages 35–69 that are attributed to smoking is still generally greater in men than in women, the male and female proportions are converging and will probably cross over in some high resource countries. Projections through to 2025 suggest that male and female smoking prevalence and smoking-attributed mortality will decrease in parallel in most developed countries towards lower limits that are not yet defined. In developing countries the model seems generally applicable to men but cannot predict whether or when women will begin smoking in large numbers. Modified criteria that describe the stages of the epidemic separately for men and women would be more generalisable to developing countries.

Conclusions The four-stage model of the cigarette epidemic still provides a reasonably useful description in many developed countries. Its relevance to developing countries could be improved by describing the stages of the epidemic separately for men and women.

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  • Competing interests None.

  • Provenance and peer review Commissioned; externally peer reviewed.

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