Smoking in Developing Countries: Current Situation and Implications for Health and Development Enis Bar and Ayda A. Yrekli World Bank, Washington, D.C. Outline Overview Health effects Determinants of ETS Review of evidence on determinants from developing countries Estimation of exposure to ETS by level of income and regions Recommendations Lack of Access to Clean Air and Child Health According to WHO, 700 million children around the world were exposed to second hand smoke in 1999. Lack of clean air is associated with lower respiratory tract infections middle ear disease chronic respiratory symptoms asthma decreased lung function sudden infant death syndrome (SIDS). Source: WHO/TFI: International Consultation on ETS and Child Health, 1999 Determinants of ETS Exposure The intensity of exposure The number of smokers The extent of cigarette consumption The behavior of smokers Legislation that restricts smoking in public and work places and its enforcement. In Developing Countries Same negative health effects But of different magnitude due to variation in the relative importance of exposure determinants, mostly smoking behavior legislation prevailing social norms and ecology, and as a result of different health and socioeconomic impact in terms of health consequences (nutrition, co-morbidity) healthcare costs absenteeism societal response (tolerance, compliance, complacency, etc) Intensity of Exposure Number of smokers around the globe 2000 Number of Smokers by Income Groups 17% 11% 44% 27% 0 100 200 300 400 500 600 LI LMI UMI HI #
o f
s m o k e r s ,
M i l l i o n 1.2 billion smokers globally 83% of global smokers (956 million) live in developing countries Prevalence rate (in 90s) Male Female Bangladesh 40 10 Turkey 59 26 Vietnam 73 4 Pakistan 36 9 China 63 4 Indonesia 63 2 Russia 63 14 Philippines 75 18 Egypt 43 5 Prevalence rate in selected developing countries Intensity of Exposure Global Cigarette Consumption 2000 In 2000, 6.2 Trillion Cigarettes Smoked Worldwide. Developing Countries Smoked 74% of Global Cigarette Consumption (4.6 Trillion Cigarettes)
Global cigarette consumption 6260 billion pieces 26% 10% 44% 21% 0 500 1000 1500 2000 2500 3000 LI LMI UMI HI Billion of cigarettes and % share in the globe Consumption (mil. pieces) % global share LI 1295 21 LMI 2733 43 UMI 613 10 HI 1619 26 Total 6260 100 China 1688 27 India 947 15 LI w/o India 348 6 LMI w/o China 1045 17 Intensity of Exposure Daily Smoke Daily 11 to 21 sticks smoked by smokers Daily cigarette consumption per smoker in 2000 11 14 12 21 0 5 10 15 20 25 LI LMI UMI HI Smokers smoking behavior: Evidence from Indonesia 1995 National Health Survey 1995 # of Total HH 31,126,882 # of HH member 109,154,973 # of smoker 38,652,636 # of smoker smoke at home 36,888,636 Average HH member 3.51 Smoker per HH 1.24 Smoker smoke at home 1.18 # of cigarettes smoked/day 11 pieces
Estimated ETS Exposure % of smokers smoke at home 95.4% Average non-smoker per household 2.26 % of HH members exposed to ETS 65% Source: Authors estimate based on National Health Survey data, 1995 Smokers smoking behavior: Evidence from Turkey % of smokers who smoke at home and in front of children in Ankara, Turkey 90% 97% 87% 84% 100% 63% 85% 60% 49% 77% Teachers Mothers Journalist Physicians Parliamentarians At home Front of children Source: Bilir, N et al. 1997. Smoking behavior and attitudes, Ankara, Turkey High ETS Exposure Among 13-15 Year Olds in Selected Low and Low-middle Income Countries
% children exposed % children exposed LMI At home At public places At home At public places Indonesia 69 84 China 54 51 Philippines 58 75 India 59 67 Jordan 67 61 Nepal 36 47 Russia 55 73 Nigeria 34 50 Bolivia 46 62 Sri Lanka 56 68 Venezuela 44 48 Ukraine 49 72 Uruguay 64 79 Zimbabwe 35 58 Source: GYTS Survey Data, 1999-00-01 Smoking restrictions in various places Countries HC Facilities Education Facilities Buses Waiting areas Entertainment centers Shopping centers China B B B B B B Philippines N N N N N N Thailand B D B D B B Iran B B B B B B Turkey D D D D D D Poland D D N D D D Indonesia B B D N N N Nigeria B B B N N N Malaysia B B B B B B B: banned, N: None, D: Designated areas Source of Data Nations: Prevalence rates USDA: Cigarette consumption WBI: Children and adult population GYTS: ETS exposure among 13-15 y of age Percentage of 1.8 billion children aged 0-14 years living in developing countries, 2000 0-14 yrs old population (mil) % share in total pop. % share in global child population Low Income 842 37% 47% Low Middle Income 628 27% 35% Upper Middle Income 172 29% 10% High Income 162 18% 9% LI and LMI 1,471 32% 82% All Developing 1,642 33% 91% Developed 162 18% 9% Total 1,805 31% 100% Source: WBI and Authors calculation
Children (0-14 years old ) and ETS exposure Selected countries with the highest child population and ETS exposure, 2000
Total (0-14 age) child pop. (Million) % share in global 0-14 age child population % of ETS Exposure 13- 15 years old students Home Public Places India 340 18.9 59 67 China 314 17.4 54 51 Indonesia 65 3.6 9 84 Pakistan 58 3.2 N/A N/A Nigeria 57 3.2 34 50 Philippines 28 2.6 58 75 Vietnam 26 1.5 N/a N/a Russia 26 1.4 55 73 Total 994 55 N/A N/A Top 10 countries w/highest child population and ETS exposure 0-14 age population % share in global 0-14 age % of 13-15 age exposed to ETS Home Public India 340 18.9 59 67 China 313 17.4 54 51 Indonesia 65 3.6 69 84 Pakistan 58 3.2 N/A N/A Nigeria 57 3.2 34 50 Bangladesh 51 2.8 N/A N/A Ethiopia 29 2.6 N/A N/A Philippines 28 2.6 58 75 Vietnam 26 1.5 N/A N/A Russia 26 1.4 55 73 Total 0-14 pop.(top 10) 944 55.0 Global 0-14 pop. 1805 Source: WBI & GYTS Over 900 million children living in developing world were exposed to ETS in 2000. Source: World Bank Estimation Number of Children (0-14 age) exposed to ETS at home and public places, 2000 (Million) 461 365 99 925 379 371 84 834 LI LMI UMI TOTAL # exposed at public places # exposed at home Percentage of children 0-14y of age exposed to ETS at home in developing countries, 2000 Income Groups # of exposed children at home in developing world (million) % share within income group % share in developing world % share globally LI 380 48% 23% 21% LMI 371 55% 22% 20% UMI 84 44% 5% 4% Total 837 46% Source: Authors calculation Percentage of children 0-14y of age exposed to ETS in public places in developing countries, 2000 Income Groups # of exposed children in public places in developing world (million) % share within income group % share in developing world % share globally LI 461 59% 28% 26% LMI 365 53% 21% 20% UMI 99 57% 7% 6% Total 925 51% Authors calculation Top 10 UMI countries with the highest number of children exposed to ETS at home and public places Region Country # of children exposed to ETS at home (mil) # of children exposed to ETS in public places (mil) LAC Brazil 25 32 LAC Mexico 17 21 ECA Turkey 12 11 AFRICA S. Africa 6 8 LAC Argentina 5 7 EAP Korea Rep. 5 6 ECA Poland 5 5 MENA S. Arabia 5 6 LAC Venezuela 4 5 EAP Malaysia 4 5 Top 10 LMI countries with the highest number of children exposed to ETS at home and public places Region Country # of children exposed to ETS at home (mil) # of children exposed to ETS in public places (mil) EAP China 171.0 166.0 EAP Indonesia 35.2 34.2 SA Pakistan 32.2 21.9 MENA Iran 16.0 14.6 EAP Philippines 15.4 15.0 MENA Egypt 15.2 13.9 ECA Russia 14.4 18.9 EAP Thailand 8.8 8.6 MENA Morocco 6.7 6.1 MENA Iraq 6.5 5.9 Top 10 LI countries with the highest number of children exposed to ETS at home and public places Region Country # of children exposed to ETS at home (mil) # of children exposed to ETS in public places (mil) SA India 199.0 227.8 SA Bangladesh 29.7 34.0 AFRICA Nigeria 18.4 27.6 EAP Vietnam 14.0 13.3 AFRICA Ethiopia 9.3 14.0 EAP Myanmar 8.5 8.1 AFRICA Congo Dem.Rep. 8.0 12.0 SA Afghanistan 6.8 7.7 MENA Yemen 5.9 3.6 SA Nepal 5.5 6.3 Results 91% of global children aged 0-14 years live in developing world. 83% of global smokers (956 million) live in developing countries. In 2000, developing countries smoked 74% of global cigarette consumption (4.6 trillion cigarettes). Lower number of cigarettes smoked per capita. Still high rate of ETS exposure at homes and public places: Over 800 million children are exposed to ETS at homes and 900 million in public places in developing countries. Most smokers still smoke near non-smokers and/or in front of children. Conclusion: Worrisome Trends and Patterns Exposure of children to ETS is larger than previously estimated Exposure is equally significant in homes and public places, although this varies depending on legislation and social norms Exposure is likely to become more significant as: Women take up smoking Countries develop and economies grow Exposure is likely to be more hazardous due to other factors, e.g. poverty, other indoor pollutants, nutritional deficiencies, etc. Conclusion: Policy Implications Implementation of Framework Convention on Tobacco Control, including legislative initiatives inclusive of ETS; Higher taxes, especially where price elasticity is higher; and Involvement of professional associations (teachers, doctors, police force), womens groups, athletes, etc to mobilize social elites to challenge and change prevailing social norms and enforce existing laws and ordinances. More comprehensive public health action, bundled with IAP and other initiatives.
Conclusion: Research Implications There is a need to: Identify culture-specific determinants of ETS amenable to interventions, including risk perception and communication; Pilot innovative programs involving role models (teachers, mothers, athletes, etc.) and targeting home environments; Estimate ETS attributable burden of disease and health care costs in developing countries; Document and cost non-health related effects of ETS, e.g. absenteeism from school, work, etc; and Seek synergism with other development issues such as IAP due to coal, biomass use, etc.