The burden of stroke—banning smoking under 25 years could save millions of lives every year

Professor Amanda Thrift

Stroke costs Australia more than $600 million a year and, globally, the burden of stroke is enormous:10.3 million new strokes a year, with most deaths occurring in low-to middle-income families.

This month, in a landmark issue of The Lancet devoted to stroke, authors of a paper discuss radical new ways to prevent stroke worldwide including options such as banning smoking in people under 21, banning people born in particular years from smoking, adding a sugar tax to soft-drinks – actions that could literally cut the burden of stroke by more than 75%.

The paper, by Monash University’s Professor Amanda Thrift and Professor Jeyaraj Pandian, from the Christian Medical College and Hospital in Ludhiana, India, and an international team, has drilled down into why countries of differing socio-economic backgrounds have so many strokes.

In the past four decades, the incidence of stroke in high-income countries has dropped by 42% while it has doubled in low-to middle-income countries. According to Professor Thrift, education about diet and lifestyle changes has significantly reduced the incidence of stroke in high income countries like the US, UK and Australia. However, in the past two decades there has been a rapid increase in smoking and poor diet in low-to middle-income countries, “particularly amongst the wealthy in these places for whom the education messages about exercise, not smoking and eating healthily are not getting traction,” she said.

According to the authors, modifiable risk factors (such as smoking and diet) account for 90% of the burden of stroke. Using the percentage of years of life lost to the disease (either to death or disability) the authors found that in 2013:

• ·         Hypertension accounts for around 60% of the burden
• ·         Diets low in vegetables account for 20%
• ·         A diet high in salt accounts for 24%
• ·         A diet low in fruit almost 40%
• ·         While sugar sweetened drinks account for a small proportion of lost years their impact has increased significantly over the two decades to 2013 by over 80% in low-to middle-income countries
• ·         Smoking remains a key factor in stroke – but has declined as a cause by 25% in high-income countries but increased by 20% in low- to middle-income countries
• ·         Other factors include air pollution, rapid weather changes, psychosocial stress and associated cardiovascular disease

According to Professor Thrift much of the data above can be linked to an increasingly sedentary lifestyle in countries like India and China. “People in low-to middle-income countries used to rely on walking and cycling as the primary mode of transport. Now it’s motorized two-wheel vehicles and cars which have significantly reduced the amount of incidental exercise that is being done,” she said.

The authors outline the preventative measures that could be used to rapidly and profoundly reduce the burden of stroke:

Citing the World Health Organization’s tobacco free initiative, called the MPOWER policy, the authors reveal that 88 countries have implemented at least one of these initiatives; reducing the number of smokers globally by 53 million and averting 22 million deaths. These initiatives range from:

• ·         price - which has its greatest impact on preventing the uptake of smoking in low- to middle-income countries
• ·         smoke free legislation and mass media campaigns – which have been more widely adopted in high income countries
• ·         bans on advertising, promotion and sponsorship are poorly adopted globally, and should be addressed, the authors advise
• ·         warning labels are extremely cost-effective and cover 47% of the world’s population (in India more than 80% of cigarette packets are covered by graphic images of cancer, similar to Australia)

In what is described as “endgame tactics” the authors suggest:

• ·         Increasing the legal age of smoking to 21 or 25
• ·         Banning the sale of tobacco to people born in a certain year creating a “tobacco-free generation”

The authors also support a tax on sugar sweetened beverages – citing evidence from Mexico where a 10% tax led to a reduction in purchasing of 6% in one year – likely leading to 20,000 fewer strokes and 19,000 fewer heart attacks “which is direct evidence of the power to improve health through taxing products that cause us harm,” Professor Thrift said.

In addition, healthy cities that encourage walking and cycling; the development of “polypills” that provide people having more than one risk factor with one tablet containing their anti-hypertensive medication and lipid lowering medication, as evidence shows that up to 50% of people with hypertension fail to take their medication correctly; are all targeted as strategies that could achieve big healthcare savings by decreasing the incidence in stroke.

Salt also carries much of the burden of causing stroke with the authors recommending educating consumers on “hidden salts” in food and government legislation targeting industry-wide lessening of salt in foods.