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RESEARCH AND PRACTICE |
Prabhat Jha is with the World Bank, Washington, DC and the Centre for Health and Development, University of Toronto, Canada. M. Kent Ranson is with the Health Policy Unit, London School of Hygiene and Tropical Medicine, London, England. Son N. Nguyen is with the World Bank, Washington, DC. Derek Yach is with the Non-Communicable Disease and Mental Health Cluster, World Health Organization, Geneva, Switzerland.
Correspondence: Requests for reprints should be sent to Prabhat Jha, MD, DPhil, Centre for Health and Development, University of Toronto, St. Michael's Hospital Research Institute, 30 Bond St, Toronto, Canada, M5B 1W8 (e-mail: prabhat.jha{at}utoronto.ca).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. We calculated regional and sex- and age-specific smoking prevalence estimates worldwide in 1995.
Methods. Sex-specific smoking prevalence data from studies in 139 countries and age distribution data from 7 studies were analyzed.
Results. Globally, 29% of persons aged 15 years or older were regular smokers in 1995. Four fifths of the world's 1.1 billion smokers lived in low- or middle-income countries. East Asian countries accounted for a disproportionately high percentage (38%) of the world's smokers. Males accounted for four fifths of all smokers, and prevalence among males and females was highest among those aged 30 to 49 years (34%).
Conclusions. Future decades will see dramatic increases in tobacco-attributable deaths in low- and middle-income regions. Although much of this excess mortality can be prevented if smokers stop smoking, quitting remains rare in low- and middle-income countries. (Am J Public Health. 2002;92:1002–1006)
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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From the perspective of global tobacco control, global or regional estimates are similarly useful. In 1997, the World Health Organization6 (WHO) calculated and published global prevalence rates of smoking. Much of the data in that review relied on smoking prevalence data from the late 1980s or earlier.
We estimated the sex- and age-specific prevalence of tobacco smoking globally and regionally for 1995. These values were used in a subsequent analysis to assess the costeffectiveness of tobacco control policies.7 This article relies chiefly on smoking prevalence data from 109 countries collected as part of the Tobacco Control Country Profiles8,9 as well as earlier data from WHO6 and the literature. We used World Bank definitions of regions, whereas WHO definitions of regions were used in the Tobacco Control Country Profiles. We excluded some of the Tobacco Control Country Profiles studies because the literature or the 1997 WHO publication (itself based on earlier surveys conducted around 1990) provided more recent estimates. 1998 was chosen as the base year for the Tobacco Control Country Profiles. We used actual 1995 population data because the bulk of the smoking surveys occurred closer to 1995 than to 1998. Our analyses attempted to estimate smoking prevalence by age category, information that has not previously been assessed at a global level.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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60) were chosen to coincide with the categories most commonly used in smoking prevalence studies.
Smoking Prevalence by Sex and Region
The results of 109 studies from the Tobacco Control Country Profiles8 plus 11 from the literature14–24 and 19 from the 1997 WHO6 review were used to estimate smoking prevalence, by sex, for each of the 7 regions. The Tobacco Control Country Profiles methods have been described elsewhere.8 For 19 countries, we chose prevalence as reported in the 1997 WHO publication, because these data were more recent.6 Whenever possible, survey data that adhered to the WHO definitions of smoking6 were selected so as to increase comparability between studies. The WHO guidelines state that respondents who report smoking at the time of the survey, or "current smokers," should be further categorized as "daily" (i.e., those who smoke at least once per day) or "occasional" smokers (i.e., those who smoke, but not every day). Although we used daily smoking as the prevalence indicator in our analyses, exclusion of 27 low- or middle-income countries that did not provide a definition of smoking only marginally changed the overall results.
We combined country-specific data to estimate regional prevalence values by weighting country estimates by the adult population (older than 15 years) of those countries. The resulting weighted average smoking prevalence rates are assumed to apply to the entire region, including those countries for which smoking prevalence is not known. When all of the sources were combined, data on smoking prevalence from individual studies were available for more than 96% of the population of each region, except eastern and central Europe and sub-Saharan Africa. For these 2 regions, data were available for 90% and 67% of the population, respectively. The median year of data for all countries was 1996.
Prevalence of Cigarette and Bidi Smoking in South Asia
In all regions with the exception of South Asia, cigarettes constitute the major form of smoked tobacco. In the countries of South Asia, however, many people smoke bidis, a hand-rolled cigarette. All calculations for South Asia were conducted separately for cigarettes and bidis. Data from 3 studies (2 from India3,25 and 1 from Sri Lanka6) suggested that 47% to 51% of the male smokers and 52% to 95% of the female smokers smoke bidis. In this analysis, it is assumed that 50% of the male and 80% of the female smokers smoke bidis, with the remainder smoking cigarettes.
Smoking Prevalence by Age Category
We attempted to find 1 large-scale study of smoking prevalence by age category for each of the 7 regions (when possible, we used the most populous country in the region). China is used as the model country for East Asia and the Pacific,23 Russia for Europe and central Asia,15,26 Brazil for Latin America and the Caribbean,27 Saudi Arabia for the Middle East and North Africa,17 India for South Asia,25,28 Sudan for sub-Saharan Africa,24 and the United States for high income.29 We validated the chosen studies, when possible, by substituting the age weights for various other countries in the same region and found little change (e.g., substituting Poland30 and Hungary31 for Russia, substituting Argentina and Chile for Brazil,27 and substituting other high-income countries32 for the United States). Ratios of smoking prevalence among older age categories compared with the 15- to 19-year age group were calculated. These ratios were applied to the entire region, including those countries for which the age ratios of smoking prevalence are not known.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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). Low- and middle-income countries, whose populations constitute four fifths of the global adult population, accounted for 82% of the world's smokers. East Asia and the Pacific, which includes China, accounted for 38% (429 million) of all smokers but only 32% of the population aged 15 years and older. Overall, smoking prevalence was highest in East Asia and the Pacific and in Europe and central Asia, at 34%, and lowest in sub-Saharan Africa, at 18%.
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) and lowest among youths aged 15 to 19 years (20%). It also was relatively low among people aged 60 and older (24%). The patterns of age-specific smoking prevalence were similar for males and females, although males had about a 4- to 5-fold higher prevalence in most age groups. |
DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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These estimates are also consistent with the 1997 WHO analysis of smoking prevalence,6 despite use of different data sources to estimate smoking prevalence for 1990, and with the Tobacco Control Country Profiles results,9 despite different base years and regional categorization. The similarity across the 3 studies is consistent with agricultural data showing that overall tobacco production has remained constant through most of the 1990s.34
Some key points are noteworthy. Low- and middle-income countries have an aggregate smoking prevalence similar to that of highincome countries, but low- and middleincome countries account for the majority (82%) of the world's smokers. Males in low-income countries have a higher prevalence of daily smoking (49%) than do males in high-income countries (37%), whereas the reverse is true for females (8% in low-income countries and 21% in high-income countries).
Our analysis is consistent with predictions that total numbers and proportion of tobaccoattributable disease burden accounted for by low-income countries will increase dramatically in future decades. WHO estimated that in 1999, about 4 million tobacco deaths occurred worldwide. About half were in China, India, Latin America and other low- or middleincome countries outside Europe, and half were in high-income countries and former socialist economies of Europe.6 Current tobacco mortality largely reflects past smoking. Per capita consumption has been higher in highincome countries than in low-income countries over the last few decades.6 However, future tobacco mortality depends largely on current smoking patterns. Peto and Lopez1 estimated, on the basis of current smoking patterns, that about 450 million cumulative tobacco deaths will have occurred by 2050, mostly in lowincome countries. Similarly, Murray and Lopez,35 using econometric models, estimated that 87% of the increase in tobacco-attributable deaths between 1990 and 2020 will occur in low-income countries. The increase in tobacco deaths is the result of both increases in the susceptible population size and increases in age-specific disease rates.
Also of importance in predicting future tobacco-attributable mortality is the prevalence of ex-smokers. Many of the future deaths expected among the 1995 cohort of smokers could be avoided if adults quit smoking. Much evidence indicates that smoking cessation reduces the risk of death from tobacco-related diseases. Among physicians in the United Kingdom, those who quit smoking before the onset of major disease avoided most of the excess hazard of smoking.36 The benefits of quitting were largest in those who quit early (between ages 35 and 44) but were still significant in those who quit later (between ages 45 and 54 years). Similar analyses suggested that cessation before middle age avoids more than 90% of the lung cancer risk attributable to tobacco.37
Percentages of former smokers are the best measure of smoking cessation at a population level. In high-income countries, percentages of former smokers have increased over the past 2 to 3 decades, and today about 30% of the male population are former smokers (Table 3). In contrast, in recent years, male percentages of former smokers were only 10% in Vietnam,22 5% in India,3 and 2% in China.23 Even these low figures may be falsely elevated, because they include people who quit because of illness. Time trend data are not available for low- and middle-income countries.
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Acknowledgments |
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We are indebted to Frank J. Chaloupka, Vendhan Gajalakshmi, Emmanuel Guindon, Alan Lopez, and Ayda Yurekli for helpful comments on the manuscript and to Marlo Corrao for providing Tobacco Control Country Profiles data.
The views represented are those of the authors and not those of the organizations sponsoring the work.
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Footnotes |
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Accepted for publication June 7, 2001.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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