Samer,Jabbour:American University of Beirut Marwan,Khawaja:United Nations Organization Carla,Obermeyer:American University of Beirut ; Conducting research to provide evidence that can contribute to improving health in a region engulfed in war and ongoing turmoil is not an easy matter. Researchers in our region must struggle with and overcome several constraints, including heavy teaching loads and institution-building priorities, leaving little time dedicated to research; absence of institutional incentives and support for conducting quality research; dearth of publicly available datasets; and absence of funding and government commitment to encourage research. But above all, we must sometimes confront enormous challenges brought about by wars and confl icts, injustice, fragmentation, insecurities, and uncertainties, which can at times suddenly dwarf our research agendas and make them irrelevant. In response to this predicament and to remain engaged, productive, and relevant we learned the impor tance of working in teams and building networks to support each other. And so, over the past decade, a group of us came together on the basis of a common understanding of the importance of the social and political contexts of health; an interest in developing frameworks of analysis that are relevant to the realities and refl ective of the needs of our region; and with the aim of giving voice to a regional perspective on issues of health and wellbeing, now hardly existing in the international literature.
Khaldoun,Nijem:Hebron University Rita,Giacaman:Community and Public Health Petter,Kristensen:National Institute of Occupational Health (STAMI) ; After the Oslo Peace Agreement between Israel and the Palestinian Liberation Organization in 1993, the Norwegian Government decided to finance projects in research and higher education between Norwegian and Palestinian institutions. In 1994, the former Rector of the University of Oslo, Prof Lucy Smith, headed a delegation to all eight Palestinian universities, two in the Gaza Strip and six in the West Bank. The local organiser was Prof Gabi Baramki, Palestinian Council for Higher Education. Dr Ebba Wergeland and Prof Espen Bjertness represented the Faculty of Medicine of University of Oslo. Representatives from the Palestinian universities presented research ideas to be considered for cooperation with University of Oslo. Hebron University presented an occupational health project among shoe factory workers, and the Institute of Community and Public Health (ICPH) at Birzeit University presented a nutritional project. Nutritional transition from traditional food based primarily on vegetables and fruits to a more westernised and processed food, combined with decreasing population physical activity, and subsequent increased risk of non-communicable diseases prompted the project. Occupational health and hygiene research has traditionally been under-recognised, even in developed countries. Awareness of health effects due to poor working conditions should be highlighted in a nation of state building. Knowledge, based on research about those health effects, is emphasised as an important component of national health plans, which aim at protecting workers. High unemployment rates, uncertainty about the future, and absence of control due to Israeli occupation contributed to a low focus on the adverse occupational health effects for both workers and employers. The project ideas resulted in a continuous cooperation from 1995 to 2009, between the Department of General Practice and Community Medicine, University of Oslo, Birzeit University, and Hebron University. For short periods, the cooperation included the Gaza Community Mental Health Programme and the Palestinian Ministry of Health in the Gaza Strip. During the early 1995 project planning phase, which involved Rita Giacaman, Awni Khatib, Gerd Holmboe-Ottesen, Petter Kristensen, and Espen Bjertness, training of local faculty and researchers at the PhD level was considered important. The first project between Hebron University and University of Oslo supported the training of two PhD candidates from Birzeit University and one from Hebron University. Early in the project cooperation, creation of a centre for Occupational Epidemiology at Hebron University and a centre for Epidemiology at Birzeit University became clear important goals. The research focus mainly dealt with central Public Health and occupational health challenges in the occupied Palestinian territory (oPt), and the training emphasised a fundamental component of public health research, notably epidemiological research methods. Furthermore, the cooperation contributed to the establishment of a Master Programme in Public Health at ICPH which we aim to develop into a Ph.D programme. Finally, the 15 years of cooperation contributed to publication of The Lancet Series in 2009, health in the oPt
Wasim,Maziak:Florida International University Fouad,Fouad:American University of Beirut Rana,Khatib:Community and Public Health ; Public policy plays a key role in improving population health and in the control of diseases, including non-communicable diseases. However, an evidence-based approach to formulating healthy public policy has been difficult to implement, partly on account of barriers that hinder integrated work between researchers and policy-makers. This paper describes a "policy effectiveness–feasibility loop" (PEFL) that brings together epidemiological modelling, local situation analysis and option appraisal to foster collaboration between researchers and policy-makers. Epidemiological modelling explores the determinants of trends in disease and the potential health benefits of modifying them. Situation analysis investigates the current conceptualization of policy, the level of policy awareness and commitment among key stakeholders, and what actually happens in practice, thereby helping to identify policy gaps. Option appraisal integrates epidemiological modelling and situation analysis to investigate the feasibility, costs and likely health benefits of various policy options. The authors illustrate how PEFL was used in a project to inform public policy for the prevention of cardiovascular diseases and diabetes in four parts of the eastern Mediterranean. They conclude that PEFL may offer a useful framework for researchers and policy-makers to successfully work together to generate evidence-based policy, and they encourage further evaluation of this approach
The main thrust of our article entails pointing to humiliation as prevalent during war and conflict, and to its association with health outcomes. Humiliation seems to be given insufficient attention by the Anglo-Saxon public health literature on conflict-affected zones, perhaps because humiliation is a construct that has diverse meanings and significance to identity and self-worth in different cultures. We understand the particular conceptualization cited by Neria and Neugebauer,3 but we also question how humiliation (a feeling or internal experience) could ever be rated independently of the study participant's own assessment. The use of inter-rater reliability3 is worrisome, given that 'levels of loss, humiliation, entrapment, and danger were rated contextually using a five-point scale', taking into account descriptive information provided in the interview itself, the narrative summary and the tape-recorded interview. However, reports of emotional reactions were ignored. Brown et al.3 did not explain how separation of the narrative from the emotional reaction is possible, and how this process is viewed as 'objective'.
The Arab world is comprised of 22 countries with a combined population of ∼360 million. The region is still at the initial stages of the tobacco epidemic, where it is expected to witness an increase in smoking levels and mounting tobacco-related morbidity and mortality in the future. Still, the bleak outlook of the tobacco epidemic in the Arab world continues to be faced with complacency in the form of underutilization of surveillance systems to monitor the tobacco epidemic and prioritize action, and failure to implement and enforce effective policies to curb the tobacco epidemic. Understandably, the focus on the Arab world carries the risk of trying to generalize to such a diverse group of countries at different level of economic and political development. Yet, tobacco control in the Arab world faces some shared patterns and common challenges that need to be addressed to advance its cause in this region. In addition, forces that promote tobacco use, such as the tobacco industry, and trends in tobacco use, such as the emerging waterpipe epidemic tend to coalesce around some shared cultural and socio-political features of this region. Generally, available data from Arab countries point at three major trends in the tobacco epidemic: (1) high prevalence of cigarette smoking among Arab men compared with women; (2) the re-emergence of waterpipe (also known as hookah, narghile, shisha, arghile) smoking as a major tobacco use method, especially among youth and (3) the failure of policy to provide an adequate response to the tobacco epidemic. In this review, we will discuss these trends, factors contributing to them, and the way forward for tobacco control in this unstable region.
Abstract Background Exposure to violence in youth may be associated with substance use and other adverse health effects. This study examined cigarette smoking in two middle-income areas with different levels and types of exposure to violence.
Methods Association of exposure to verbal and physical violence with cigarette smoking in the West Bank oPt (2008) and in Jujuy Argentina (2006) was examined using cross-sectional surveys of 14 to 17-year old youth in 7th to 10th grade using probabilistic sampling.
Results Violence exposure rates were more than double for Palestinian girls (99.6% vs. 41.2%) and boys (98.7% vs. 41.1%) compared with Argentinians. The rate of current cigarette smoking was significantly higher among Argentinian girls compared with Palestinian girls (33.1% vs. 7.1%, p < 0.001). Exposure to verbal violence from family and to physical violence increased the odds of current cigarette smoking, respectively, among Argentinian girls (aOR = 1.3, 95% CI = 1.0–1.7; aOR = 2.5, 95%CI = 1.7–3.8), Palestinian girls (aOR 2.2, 95%CI = 1.1–2.4; aOR = 2.0, 95%CI = 1.1–3.6) and Argentinian boys (aOR = 1.5, 95%CI = 1.1–2.0; aOR = 2.2, 95%CI = 1.6–3.0), but not among Palestinian boys.
Conclusion Findings highlight the importance of producing context and gender specific evidence from exposure to violence, to inform and increase the impact of targeted smoking prevention strategies.
Luis,Duque: Eliseo,Perez-Stable: ; Background Despite efforts to reduce the prevalence of tobacco smoking, cessation is a major challenge for adolescents and teenagers in low-income and middle-income countries. Smoking prevalence and the association between it and selected determinants, including violence, in adolescents and teenagers were investigated in the occupied Palestinian territory (oPt), Colombia, and Argentina. Methods Three cross-sectional surveys were undertaken in 2006 in Jujuy, Argentina, and in 2008 in West Bank, oPt, and Medellin, Colombia. Children (aged 12–17 years) were selected by use of cluster sampling of schools in all three countries, and neighbourhoods in Colombia. They completed a self-administered questionnaire that included questions about smoking habits, demographic characteristics, and exposure to violence. The main analyses were χ² test and logistic regression, and were restricted to the questions for the comparable age group (14–15 years) in the three settings. Findings 3238 (86%) of 3765 Argentinian children, 3107 (99%) of 3138 Palestinian children, and 1998 (99%) of 2018 Colombian children participated in the study. Prevalence of smoking was 325 (23%) of 1386 Palestinian, 688 (31%) of 2254 Argentinian, and 104 (8%) of 1324 Colombian children. Minor differences were noted in smoking prevalence between Colombian (42 [7%] of 644 girls vs 62 [9%] of 680 boys; 3%, 95% CI –1 to 6) and Argentinian boys and girls (357 [29%] of 1238 vs 331 [33%] of 1015; 4%; –3 to 11), whereas the difference was greater between Palestinian boys (283 [37%] of 770) and girls (42 [7%] of 616; 30%, 20 to 39). Palestinian and Argentinian children tried smoking before the age of 8 years with prevalences of 28 (9%) of 323 and 63 (9%) of 688, respectively, compared with 15 (4%) of 412 Colombian children. 130 (40%) of 323 Palestinian, 180 (44%) of 412 Colombian, and 313 (46%) of 684 Argentinian children smoked cigarettes most often when aged 12–13 years. Palestinian children more often reported exposure to physical (554 [40%] of 1386) and verbal (585 [42%] of 1386) violence by their parents than did Argentinian children (582 [26%] of 2241 and 312 [14%] of 2241, respectively). Palestinian and Argentinian children reported similar amounts of exposure to physical violence from strangers (178 [13%] of 1386 vs 291 [13%] of 2243, respectively) and weapons (136 [10%] of 1386 vs 190 [8%] of 2243, respectively). The prevalence of smoking among Argentinian children who reported exposure to physical violence from strangers (soldiers or gang members) was 158 (54%) of 291 (odds ratio for smoking vs non-smoking children 3·21, 2·50 to 4·13) and 96 (51%) of 190 (2·55, 1·89 to 3·43) in those exposed to weapons compared with 98 (55%) of 178 (3·08, 2·17 to 4·39) and 72 (53%) of 136 Palestinian children (2·79, 1·91 to 4·08), respectively. Interpretation The results indicate international differences, but support the association between exposure to violence and smoking habits. Policy makers and educators need to give attention to the high prevalence of smoking among adolescents and teenagers living under conflict.
Abla,Sibai:American University of Beirut Khader,Yousef:Jordan University of Science and Technology Awad,Mataria:World Health Organization WHO ; According to the results of the Global Burden of Disease Study 2010, the burden of non-communicable diseases (cardiovascular disease, cancer, chronic lung diseases, and diabetes) in the Arab world has increased, with variations between countries of diff erent income levels. Behavioural risk factors, including tobacco use, unhealthy diets, and physical inactivity are prevalent, and obesity in adults and children has reached an alarming level. Despite epidemiological evidence, the policy response to non-communicable diseases has been weak. So far, Arab governments have not placed a suffi ciently high priority on addressing the high prevalence of non-communicable diseases, with variations in policies between countries and overall weak implementation. Cost-eff ective and evidence-based prevention and treatment interventions have already been identifi ed. The implementation of these interventions, beginning with immediate action on salt reduction and stricter implementation of tobacco control measures, will address the rise in major risk factors. Implementation of an eff ective response to the non-communicable-disease crisis will need political commitment, multisectoral action, strengthened health systems, and continuous monitoring and assessment of progress. Arab governments should be held accountable for their UN commitments to address the crisis. Engagement in the global monitoring framework for non-communicable diseases should promote accountability for eff ective action. The human and economic burden leaves no room for inaction
Article published in : Journal of Epidemiol Community Health, September 2010, vol. 64, Suppl. 1 ; Historically, policy initiatives have made variable contributions to improvements in public health. Today there is a growing interest in translating evidence from health research into healthy public policy. Although research evidence may be a component of policy development, it is rarely enough, because policy makers are subject to a wide range of influences. Furthermore, researchers and policy makers usually work within different time frames and rules of evidence. There is a growing, albeit limited, literature on how researchers can most effectively engage with policy makers. Evidence suggests that more active and effective dialogue between researchers and policy makers is needed, in the formulation of research questions, presentation of evidence, and drafting and choice of policy options. Aim To develop, implement, and evaluate an interactive approach to informing policy for the prevention and management of cardiovascular disease (CVD) and diabetes. Setting This work is being undertaken in four eastern Mediterranean territories, known to have high burdens of CVD and diabetes: Palestine, Tunisia, Turkey and Syria. Methods and results Available epidemiological data are being identified, appraised and used to populate the IMPACT CHD Policy Model in order to examine CHD trends. Two corresponding epidemiological models have been developed to examine trends in type 2 diabetes and ischaemic stroke. An intensive review of the literature and consultation assists in the identification of efficacious policy interventions. A situation analysis is being undertaken within each country using mixed methods, which include: key informant and in depth interviews, document reviews, and participant observation. Its aim is to review current policy (stated and implemented), perceived facilitators and barriers to policy change, including health beliefs, and aspects of the health system. Policy makers are explicitly involved as key informants, participants, advisors and "lobbyists". The epidemiological modelling, evidence based reviews, and situation analyses are together being used to generate diverse policy
In: Bulletin of the World Health Organization: the international journal of public health = Bulletin de l'Organisation Mondiale de la Santé, Band 90, Heft 11, S. 847-853
Wasim,Maziak:Florida International University Fouad,Fouad:American University of Beirut Rana,Khatib:Community and Public Health ; Article published in : Bull World Health Organ 2012 ; 90 pp. 847–853 | doi:10.2471/BLT.12.104968 ; Public policy plays a key role in improving population health and in the control of diseases, including non-communicable diseases. However, an evidence-based approach to formulating healthy public policy has been difficult to implement, partly on account of barriers that hinder integrated work between researchers and policy-makers. This paper describes a "policy effectiveness–feasibility loop" (PEFL) that brings together epidemiological modelling, local situation analysis and option appraisal to foster collaboration between researchers and policy-makers. Epidemiological modelling explores the determinants of trends in disease and the potential health benefits of modifying them. Situation analysis investigates the current conceptualization of policy, the level of policy awareness and commitment among key stakeholders, and what actually happens in practice, thereby helping to identify policy gaps. Option appraisal integrates epidemiological modelling and situation analysis to investigate the feasibility, costs and likely health benefits of various policy options. The authors illustrate how PEFL was used in a project to inform public policy for the prevention of cardiovascular diseases and diabetes in four parts of the eastern Mediterranean. They conclude that PEFL may offer a useful framework for researchers and policy-makers to successfully work together to generate evidence-based policy, and they encourage further evaluation of this approach.
Background - The scale-up of tobacco control, especially after the adoption of the Framework Convention for Tobacco Control, is a major public health success story. Nonetheless, smoking remains a leading risk for early death and disability worldwide, and therefore continues to require sustained political commitment. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) offers a robust platform through which global, regional, and national progress toward achieving smoking-related targets can be assessed. Methods - We synthesised 2818 data sources with spatiotemporal Gaussian process regression and produced estimates of daily smoking prevalence by sex, age group, and year for 195 countries and territories from 1990 to 2015. We analysed 38 risk-outcome pairs to generate estimates of smoking-attributable mortality and disease burden, as measured by disability-adjusted life-years (DALYs). We then performed a cohort analysis of smoking prevalence by birth-year cohort to better understand temporal age patterns in smoking. We also did a decomposition analysis, in which we parsed out changes in all-cause smoking-attributable DALYs due to changes in population growth, population ageing, smoking prevalence, and risk-deleted DALY rates. Finally, we explored results by level of development using the Socio-demographic Index (SDI). Findings - Worldwide, the age-standardised prevalence of daily smoking was 25·0% (95% uncertainty interval [UI] 24·2–25·7) for men and 5·4% (5·1–5·7) for women, representing 28·4% (25·8–31·1) and 34·4% (29·4–38·6) reductions, respectively, since 1990. A greater percentage of countries and territories achieved significant annualised rates of decline in smoking prevalence from 1990 to 2005 than in between 2005 and 2015; however, only four countries had significant annualised increases in smoking prevalence between 2005 and 2015 (Congo [Brazzaville] and Azerbaijan for men and Kuwait and Timor-Leste for women). In 2015, 11·5% of global deaths (6·4 million [95% UI 5·7–7·0 million]) were attributable to smoking worldwide, of which 52·2% took place in four countries (China, India, the USA, and Russia). Smoking was ranked among the five leading risk factors by DALYs in 109 countries and territories in 2015, rising from 88 geographies in 1990. In terms of birth cohorts, male smoking prevalence followed similar age patterns across levels of SDI, whereas much more heterogeneity was found in age patterns for female smokers by level of development. While smoking prevalence and risk-deleted DALY rates mostly decreased by sex and SDI quintile, population growth, population ageing, or a combination of both, drove rises in overall smoking-attributable DALYs in low-SDI to middle-SDI geographies between 2005 and 2015. Interpretation - The pace of progress in reducing smoking prevalence has been heterogeneous across geographies, development status, and sex, and as highlighted by more recent trends, maintaining past rates of decline should not be taken for granted, especially in women and in low-SDI to middle-SDI countries. Beyond the effect of the tobacco industry and societal mores, a crucial challenge facing tobacco control initiatives is that demographic forces are poised to heighten smoking's global toll, unless progress in preventing initiation and promoting cessation can be substantially accelerated. Greater success in tobacco control is possible but requires effective, comprehensive, and adequately implemented and enforced policies, which might in turn require global and national levels of political commitment beyond what has been achieved during the past 25 years.
Background The scale-up of tobacco control, especially after the adoption of the Framework Convention for Tobacco Control, is a major public health success story. Nonetheless, smoking remains a leading risk for early death and disability worldwide, and therefore continues to require sustained political commitment. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) offers a robust platform through which global, regional, and national progress toward achieving smoking-related targets can be assessed. Methods We synthesised 2818 data sources with spatiotemporal Gaussian process regression and produced estimates of daily smoking prevalence by sex, age group, and year for 195 countries and territories from 1990 to 2015. We analysed 38 risk-outcome pairs to generate estimates of smoking-attributable mortality and disease burden, as measured by disability-adjusted life-years (DALYs). We then performed a cohort analysis of smoking prevalence by birth-year cohort to better understand temporal age patterns in smoking. We also did a decomposition analysis, in which we parsed out changes in all-cause smoking-attributable DALYs due to changes in population growth, population ageing, smoking prevalence, and risk-deleted DALY rates. Finally, we explored results by level of development using the Socio-demographic Index (SDI). Findings Worldwide, the age-standardised prevalence of daily smoking was 25·0% (95% uncertainty interval [UI] 24·2–25·7) for men and 5·4% (5·1–5·7) for women, representing 28·4% (25·8–31·1) and 34·4% (29·4–38·6) reductions, respectively, since 1990. A greater percentage of countries and territories achieved significant annualised rates of decline in smoking prevalence from 1990 to 2005 than in between 2005 and 2015; however, only four countries had significant annualised increases in smoking prevalence between 2005 and 2015 (Congo [Brazzaville] and Azerbaijan for men and Kuwait and Timor-Leste for women). In 2015, 11·5% of global deaths (6·4 million [95% UI 5·7–7·0 million]) were attributable to smoking worldwide, of which 52·2% took place in four countries (China, India, the USA, and Russia). Smoking was ranked among the five leading risk factors by DALYs in 109 countries and territories in 2015, rising from 88 geographies in 1990. In terms of birth cohorts, male smoking prevalence followed similar age patterns across levels of SDI, whereas much more heterogeneity was found in age patterns for female smokers by level of development. While smoking prevalence and risk-deleted DALY rates mostly decreased by sex and SDI quintile, population growth, population ageing, or a combination of both, drove rises in overall smokingattributable DALYs in low-SDI to middle-SDI geographies between 2005 and 2015. Interpretation The pace of progress in reducing smoking prevalence has been heterogeneous across geographies, development status, and sex, and as highlighted by more recent trends, maintaining past rates of decline should not be taken for granted, especially in women and in low-SDI to middle-SDI countries. Beyond the effect of the tobacco industry and societal mores, a crucial challenge facing tobacco control initiatives is that demographic forces are poised to heighten smoking's global toll, unless progress in preventing initiation and promoting cessation can be substantially accelerated. Greater success in tobacco control is possible but requires effective, comprehensive, and adequately implemented and enforced policies, which might in turn require global and national levels of political commitment beyond what has been achieved during the past 25 years.
Background The scale-up of tobacco control, especially after the adoption of the Framework Convention for Tobacco Control, is a major public health success story. Nonetheless, smoking remains a leading risk for early death and disability worldwide, and therefore continues to require sustained political commitment. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) offers a robust platform through which global, regional, and national progress toward achieving smoking-related targets can be assessed. Methods We synthesised 2818 data sources with spatiotemporal Gaussian process regression and produced estimates of daily smoking prevalence by sex, age group, and year for 195 countries and territories from 1990 to 2015. We analysed 38 risk-outcome pairs to generate estimates of smoking-attributable mortality and disease burden, as measured by disability-adjusted life-years (DALYs). We then performed a cohort analysis of smoking prevalence by birth-year cohort to better understand temporal age patterns in smoking. We also did a decomposition analysis, in which we parsed out changes in all-cause smoking-attributable DALYs due to changes in population growth, population ageing, smoking prevalence, and risk-deleted DALY rates. Finally, we explored results by level of development using the Socio-demographic Index (SDI). Findings Worldwide, the age-standardised prevalence of daily smoking was 25.0% (95% uncertainty interval [UI] 24.2-25.7) for men and 5.4% (5.1-5.7) for women, representing 28.4% (25.8-31.1) and 34.4% (29.4-38.6) reductions, respectively, since 1990. A greater percentage of countries and territories achieved significant annualised rates of decline in smoking prevalence from 1990 to 2005 than in between 2005 and 2015; however, only four countries had significant annualised increases in smoking prevalence between 2005 and 2015 (Congo [Brazzaville] and Azerbaijan for men and Kuwait and Timor-Leste for women). In 2015, 11.5% of global deaths (6.4 million [95% UI 5.7-7.0 million]) were attributable to smoking worldwide, of which 52.2% took place in four countries (China, India, the USA, and Russia). Smoking was ranked among the five leading risk factors by DALYs in 109 countries and territories in 2015, rising from 88 geographies in 1990. In terms of birth cohorts, male smoking prevalence followed similar age patterns across levels of SDI, whereas much more heterogeneity was found in age patterns for female smokers by level of development. While smoking prevalence and risk-deleted DALY rates mostly decreased by sex and SDI quintile, population growth, population ageing, or a combination of both, drove rises in overall smoking-attributable DALYs in low-SDI to middle-SDI geographies between 2005 and 2015. Interpretation The pace of progress in reducing smoking prevalence has been heterogeneous across geographies, development status, and sex, and as highlighted by more recent trends, maintaining past rates of decline should not be taken for granted, especially in women and in low-SDI to middle-SDI countries. Beyond the effect of the tobacco industry and societal mores, a crucial challenge facing tobacco control initiatives is that demographic forces are poised to heighten smoking's global toll, unless progress in preventing initiation and promoting cessation can be substantially accelerated. Greater success in tobacco control is possible but requires effective, comprehensive, and adequately implemented and enforced policies, which might in turn require global and national levels of political commitment beyond what has been achieved during the past 25 years.
Correction in: LANCET Volume: 390 Issue: 10103 Pages: 1644-1644 Published: OCT 7 2017 . ; Background The scale-up of tobacco control, especially after the adoption of the Framework Convention for Tobacco Control, is a major public health success story. Nonetheless, smoking remains a leading risk for early death and disability worldwide, and therefore continues to require sustained political commitment. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) offers a robust platform through which global, regional, and national progress toward achieving smoking-related targets can be assessed. Methods We synthesised 2818 data sources with spatiotemporal Gaussian process regression and produced estimates of daily smoking prevalence by sex, age group, and year for 195 countries and territories from 1990 to 2015. We analysed 38 risk-outcome pairs to generate estimates of smoking-attributable mortality and disease burden, as measured by disability-adjusted life-years (DALYs). We then performed a cohort analysis of smoking prevalence by birth-year cohort to better understand temporal age patterns in smoking. We also did a decomposition analysis, in which we parsed out changes in all-cause smoking-attributable DALYs due to changes in population growth, population ageing, smoking prevalence, and risk-deleted DALY rates. Finally, we explored results by level of development using the Socio-demographic Index (SDI). Findings Worldwide, the age-standardised prevalence of daily smoking was 25.0% (95% uncertainty interval [UI] 24.2-25.7) for men and 5.4% (5.1-5.7) for women, representing 28.4% (25.8-31.1) and 34.4% (29.4-38.6) reductions, respectively, since 1990. A greater percentage of countries and territories achieved significant annualised rates of decline in smoking prevalence from 1990 to 2005 than in between 2005 and 2015; however, only four countries had significant annualised increases in smoking prevalence between 2005 and 2015 (Congo [Brazzaville] and Azerbaijan for men and Kuwait and Timor-Leste for women). In 2015, 11.5% of global deaths (6.4 million [95% UI 5.7-7.0 million]) were attributable to smoking worldwide, of which 52.2% took place in four countries (China, India, the USA, and Russia). Smoking was ranked among the five leading risk factors by DALYs in 109 countries and territories in 2015, rising from 88 geographies in 1990. In terms of birth cohorts, male smoking prevalence followed similar age patterns across levels of SDI, whereas much more heterogeneity was found in age patterns for female smokers by level of development. While smoking prevalence and risk-deleted DALY rates mostly decreased by sex and SDI quintile, population growth, population ageing, or a combination of both, drove rises in overall smoking-attributable DALYs in low-SDI to middle-SDI geographies between 2005 and 2015. Interpretation The pace of progress in reducing smoking prevalence has been heterogeneous across geographies, development status, and sex, and as highlighted by more recent trends, maintaining past rates of decline should not be taken for granted, especially in women and in low-SDI to middle-SDI countries. Beyond the effect of the tobacco industry and societal mores, a crucial challenge facing tobacco control initiatives is that demographic forces are poised to heighten smoking's global toll, unless progress in preventing initiation and promoting cessation can be substantially accelerated. Greater success in tobacco control is possible but requires effective, comprehensive, and adequately implemented and enforced policies, which might in turn require global and national levels of political commitment beyond what has been achieved during the past 25 years. ; Bill & Melinda Gates Foundation and Bloomberg Philanthropies. ; Peer Reviewed