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Childrens Exposure to

Environmental Smoke / Involuntary


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.

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