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RESEARCH AND PRACTICE |
Anna Gilmore, Joceline Pomerleau, and Martin McKee are with the European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, London, England. Richard Rose is with the Centre for the Study of Public Policy, University of Strathclyde, Glasgow, Scotland. At the time of the study, Christian W. Haerpfer was with the Institute for Advanced Studies, Vienna, Austria. David Rotman is with the Center of Sociological and Political Studies, Belarus State University, Minsk, Belarus. Sergej Tumanov is with the Centre for Sociological Studies, Moscow State University, Moscow, Russia.
Correspondence: Requests for reprints should be sent to Anna Gilmore, MSc, MFPH, European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, England (e-mail: anna.gilmore{at}lshtm.ac.uk).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. We sought to provide comparative data on smoking habits in countries of the former Soviet Union.
Methods. We conducted cross-sectional surveys in 8 former Soviet countries with representative national samples of the population 18 years or older.
Results. Smoking rates varied among men, from 43.3% to 65.3% among the countries examined. Results showed that smoking among women remains uncommon in Armenia, Georgia, Kyrgyzstan, and Moldova (rates of 2.4%–6.3%). In Belarus, Ukraine, Kazakhstan, and Russia, rates were higher (9.3%–15.5%). Men start smoking at significantly younger ages than women, smoke more cigarettes per day, and are more likely to be nicotine dependent.
Conclusions. Smoking rates among men in these countries have been high for some time and remain among the highest in the world. Smoking rates among women have increased from previous years and appear to reflect transnational tobacco company activity.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Despite these deplorably high levels of tobacco-related mortality, relatively little is known about smoking prevalence rates in the region. Virtually no recent or reliable data exist for the central Asian countries (Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan),2,3 and recent surveys conducted in Georgia have been limited to the capital, Tbilisi.4,5 Data from elsewhere in the Caucasus (Armenia, Azerbaijan) are scarce,6 and historical figures7 are inconsistent with later findings, leading authors to rely on anecdotal reports of smoking rates.8
Historical3 and more recent data, derived largely from Russia,9 Ukraine,10 Belarus,11 and the Baltic states,12 show—perhaps unsurprisingly, given the mortality figures just described—that smoking rates among men are high (45%–60%) while rates are far lower among women (1%–20%).2 The higher rates previously seen among Estonian women are now being matched by rates among women in the other Baltic states2,12,13 and by women in other urban areas.9,10 Unfortunately, other than the Baltic states, few countries collect information using similar data collection tools, thereby precluding accurate between-country comparisons.
These issues underlie the need in the former Soviet Union for comparable and accurate data on smoking prevalence, given that such data are widely recognized as a prerequisite for the development of effective public health policies.14–16 This need is made more urgent by the profound changes occurring as a result of the former Soviet Union’s recent economic transition and, more specifically, by the changes taking place in its tobacco industry.17 The latter were first felt as soon as these formerly closed markets opened, with a rapid influx of cigarette imports and advertising.18–20 Later, as part of the large-scale privatization of state assets, most of the newly independent states privatized their tobacco industries, and the transnational tobacco companies established a local manufacturing presence, investing more than $2.7 billion in 10 countries of the former Soviet Union between 1991 and 2000.21 Evidence from the industry’s previous entry into Asia suggests that these changes are likely to have a significant upward impact on cigarette consumption.22,23
In response to these and other health and social issues facing the region, a major research project—the Living Conditions, Lifestyles and Health Study—was commissioned as part of the European Union’s Copernicus program. This investigation involved surveys conducted in 8 of the 15 newly independent states: Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, and Ukraine.24 We present data on smoking prevalence, including age- and gender-specific smoking rates, age at initiation of smoking, and indicators of nicotine dependence.
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METHODS |
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Samples were selected via multistage random sampling with stratification by region and area. Within each primary sampling unit, households were selected according to standardized random route procedures; the exception was Armenia, where household lists were used to provide a random sample. Within each household, the adult with the birthday nearest to the date of the survey was selected to be interviewed. At least 2000 respondents were included in each country; 4006 residents of the Russian Federation and 2400 residents of Ukraine were interviewed, reflecting the larger and more diverse populations of these countries.
Questionnaire Design
The first draft of the questionnaire was created, in consultation with country representatives, from preexisting surveys conducted in other transition countries9,10,12 and from New Russia Barometer surveys27 adjusted to national contexts. It was developed in English, translated into national languages, back-translated to ensure consistency, and pilot tested in each country. Trained interviewers administered the questionnaire in respondents’ homes.
Statistical Analyses
Stata (Version 6; Stata Corp, College Station, Tex) was used to analyze the data. As a means of reducing the skewness of their distribution, the continuous variables of age at smoking initiation and smoking duration were transformed, via log-normal transformations, before analyses were conducted; however, they were returned to their original units in computing results.
Current smokers were defined as respondents reporting currently smoking at least 1 cigarette per day. We calculated age- and gender-specific smoking prevalence rates for each country. Given the negative health effects of early initiation, we examined age at smoking initiation among current smokers, as well as number of cigarettes smoked. We assessed level of nicotine dependence, an indication of smokers’ ability or inability to quit, by identifying the percentage of current smokers who smoked more than 20 cigarettes per day and smoked within an hour of waking. This level of use is equivalent to a score of 3 or more on the abbreviated Fagerstrom dependency scale28,29 and indicates moderate (score of 3 or 4) to severe (score of 5 or above) dependency.
Within each country, gender differences in smoking habits were assessed with 
2 tests and 2-sample t tests; variations according to age group were estimated via logistic regression analyses in which the 18- to 29-year age group was the reference category. Logistic regression analyses with Russia as the baseline were used in making between-country comparisons in likelihood of smoking, while analyses of variance combined with Bonferroni multiple comparison tests were used in comparing geometric mean ages at smoking initiation. To allow for the large number of comparisons, we used 99% confidence intervals and set the significance level at .01.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Sample Characteristics and Representativeness
The samples clearly reflected the diversity of the region and were broadly representative of their overall populations (Table 1
). Comparisons of the present data and official data are potentially limited by the failure of some of the country data to fully capture posttransition migration and other factors,30 but they suggest slight underrepresentations of men in Armenia and Ukraine, of the urban population in Armenia, and of the rural population in Kyrgyzstan. Age group comparisons among the respondents 20 years or older suggested a tendency for the oldest age group to be overrepresented at the expense of the youngest age group, particularly in Armenia, Moldova, and Ukraine.
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). Rates of current smoking were lowest in Moldova (43.3%) and Kyrgyzstan (51.0%) and highest in Kazakhstan (65.3%), Armenia (61.8%), and Russia (60.4%). Smoking rates in Russia were not distinguishable from those in Kazakhstan, Armenia, or Belarus but were significantly higher than those observed in Moldova, Kyrgyzstan, Ukraine, and Georgia (P < .01; data not shown).
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The relationship between smoking and age varied by gender. Among men, with the exception of those residing in Moldova, smoking prevalence rates varied little between the ages of 18 and 59 years but then declined more markedly in men above the age of 60 years (Table 2
, Figure 1). This decline with age was accounted for by increases in the older groups in terms of percentages of former smokers and never smokers. Among women, the overall trend was a decrease in reports of both current and former smoking with increasing age; very low smoking rates were observed in the oldest age group (rates of reported lifetime smoking varied from 0.8%–3.9%). However, closer inspection of the data suggested that the countries could be divided into 2 groups. In the first group (Russia, Belarus, Ukraine, and Kazakhstan), rates of current and ever smoking implied that initiation of smoking had increased rapidly between generations, especially in the youngest age group (Table 2, Figure 1). In the second group (Armenia, Georgia, Kyrgyzstan, and Moldova), the age trends were less obvious and were nonsignificant (with the exception of the comparison of the oldest and youngest age groups in Moldova).
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). Far fewer women reported beginning in childhood, and sizable percentages began after the age of 20 years; for example, 86% of women residing in Armenia and more than 40% of women residing in Georgia, Kyrgyzstan, and Moldova reported that they initiated smoking after this age. These gender differences were significant in all of the countries under study.
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Amount Smoked and Nicotine Dependence
Men were found to smoke more cigarettes than women; the majority of men smoked 10 or more cigarettes per day, while most women smoked fewer than 10 per day. Between-gender differences in percentages of respondents smoking more than 20 cigarettes per day were significant only in the case of Belarus, Kazakhstan, Russia, and Ukraine (P < .001).
The majority of smokers reported smoking their first cigarette within an hour of waking, although, in all countries other than Georgia, a far higher proportion of men than women did so (P < .01). Thus, men were more likely to be moderately to severely dependent on nicotine, although gender differences were significant only for Belarus, Kazakhstan, Russia, and Ukraine.
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DISCUSSION |
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Study Limitations
The underrepresentation of men in Armenia and Ukraine should not have affected the gender-specific rates observed, but, as a result of the urban/rural differences in the composition of the sample, prevalence rates in Kyrgyzstan (where urban areas were overrepresented) may have been overestimated, and prevalence rates in Armenia (where urban areas were underrepresented) may have been underestimated. However, these discrepancies were likely to affect only the data relating to female respondents.9–11 The age group disparities noted were minor but would tend to lead to underestimates of smoking prevalence.
In addition, the surveys were based on self-reported smoking status; there was no independent biochemical validation, and thus the smoking rates observed may have been affected by reporting bias. Although there is concern on the part of some that self-reports of smoking status may produce underestimates of smoking levels, studies conducted in Western countries suggest that this technique is sensitive and specific; they also suggest that more accurate responses are provided in interviewer-administered questionnaires than in self-completed questionnaires.33 The only study conducted in the former Soviet Union that has addressed this issue showed that, among individuals claiming to be nonsmokers, 13% (48/368) of women and 17% (12/375) of men in rural northwestern Russia were in fact, according to blood cotinine levels, likely to be smokers, compared with only 2% of men and women in Finland.34 Given the far lower prevalence of smoking among women, this had disproportionately large effects on reported rates of smoking among women. Although our questionnaires were administered by interviewers in respondents’ homes, potentially making it more difficult for respondents who smoked to deny doing so, we may have underestimated smoking prevalence rates, particularly in the case of women residing in areas where smoking remains culturally unacceptable.
A final shortfall of the present study was the failure to measure smokeless tobacco use, which is relatively common in parts of the former Soviet Union, mainly Azerbaijan, Tajikistan, and Turkmenistan. However, although chewing tobacco is used in some of the southern regions of Kyrgyzstan, cigarettes are the main form of tobacco used there as well as in all of the other countries in which surveys were conducted.8,35
Findings
The results of our study confirm that smoking rates among men in this region are among the highest in the world and higher than the maximum rates recorded in the United States at the peak of its epidemic; rates above 50% were observed in all countries other than Moldova and reached 60% or more in Armenia, Kazakhstan, and Russia. Elsewhere in Europe, rates above 50% are seen only in Turkey (51%) and Slovakia (56%), and worldwide fewer than 20 countries report rates of more than 60%.6
In the case of men, the lower prevalence of current smokers and higher prevalence of never and former smokers among those 60 years or older probably reflect the disproportionate number of premature deaths among current smokers relative to never and former smokers. However, a cohort effect has been shown in the former Soviet Union, with those who were teenagers between 1945 and 1953 carrying forward lower smoking rates because cigarettes, like other consumer goods, were in short supply in the period of postwar austerity under Stalin.36,37 This cohort effect is also thought to account for the unexpected current decline in male lung cancer deaths,36 which must be set against the overall rise in male tobacco-related mortality1 and, in particular, increases in the already staggeringly high number of cardiovascular deaths.2
In comparison with male smoking patterns, smoking among women is far less common, varies more between countries, and exhibits a different age-specific pattern. Although rates of lifetime smoking are below 4% among individuals older than 60 years in all 8 countries, in the 4 countries with the highest smoking rates among women (Belarus, Ka-zakhstan, Russia, and Ukraine), smoking is now significantly more common among members of the younger generations; risk ratios between the youngest and oldest age groups range from 12.2 to 37.3, compared with a range of 1.0 to 5.5 in the other 4 countries.
Lopez et al.38 outlined a 4-stage model of the patterns of a smoking epidemic based on observations from Western countries. In this model, such an epidemic is described as involving an initial rise in male smoking followed by a rise in female smoking 1 to 2 decades later, after which each plateaus and then falls as a result of tobacco-related mortality, finally rising to a peak decades later. Our findings suggest that the former Soviet Union’s tobacco epidemic may have developed differently. Male smoking has a long history in this region. The first accounts of tobacco smoking in Russia date from the 17th century,39 papirossi (a type of cigarette, popular in the former Soviet Union, characterized by a long, hollow mouthpiece that can be twisted before smoking) were first mentioned in 1844,39 and cigarette factories were first constructed later in the 19th century.40,41 Historical data on smoking3 and high male tobacco-related mortality rates1 suggest that smoking among men has been at a high level for some time and, contrary to the predictions of the 4-stage model just mentioned, has failed to exhibit a postpeak decline.
Smoking among women remains relatively uncommon, and rates have been far slower to rise than would be expected given male rates in the former Soviet Union and trends observed in the West. Indeed, it appears that female rates began to increase only in the mid-to late 1990s, when transnational tobacco companies arrived with their carefully targeted marketing strategies.18–20 Therefore, although the exact stage of the epidemic varies slightly between the countries of the former Soviet Union, overall we suggest that men have remained between stages 3 and 4, with high rates of both smoking and mortality, while women in some countries are at stage 1 and others at stage 2, the latter with more rapidly rising smoking rates. Although rates of cardiovascular disease have been increasing, this can largely be explained by risk factors other than tobacco (including diet and stress), and female lung cancer rates have yet to increase.
Comparisons between our results and previous data are problematic given that much of the information that exists is fragmentary, of uncertain quality, and rarely nationally representative. This is particularly the case in the central Asian and Caucasian states, although limited data from Armenia and Moldova gathered between 1998 and 2001 suggest few changes in smoking prevalence rates2,6; data from Kazakhstan suggest small increases from the 60% male and 7% female prevalence rates recorded in 1996.2 More data are available for Belarus, Russia, and Ukraine. These data suggest that smoking rates in men have changed little,2,10,11,42 although in Russia they appeared to rise between the 1970s and 1980s2,3,7 and into the mid-1990s, with little subsequent change. Among women, rates appear to have increased in all 3 countries,2,11 and Russian data suggest that although rates have been rising since the 1970s, increases were most notable during the 1990s.3,7,9,43
Between-gender and intercountry differences in smoking prevalence rates are reflected in other smoking indicators as well; for example, men are more likely than women to start smoking when they are young, to smoke more heavily, and to be nicotine dependent. Two separate groupings of countries appeared to emerge from the between-country comparisons: Belarus, Kazakhstan, Russia, and Ukraine, on one hand, and Armenia, Georgia, Kyrgyzstan, and Moldova, on the other. In addition to exhibiting higher smoking rates among women and more pronounced age-specific trends, the former group tended to show lower ages at smoking initiation (particularly in comparison with Armenia, Georgia, and Moldova) along with more marked gender differences in regard to number of cigarettes smoked per day and level of nicotine dependency.
The differences observed in this study suggest that smoking patterns in Armenia, Georgia, Moldova, and Kyrgyzstan are more traditional than those in Belarus, Kazakhstan, Russia, and Ukraine. This situation can be explained by the differing degree of transnational tobacco company penetration.21,44 Industry in Moldova continues to be in the form of a state-owned monopoly; industry in Georgia and Armenia has been privatized, but this change was rather recent (occurring after 1997), and none of the major transnational tobacco companies have invested directly in those countries.21 Kazakhstan, Russia, and Ukraine, by contrast, saw major investments from most major transnational tobacco companies beginning in the early 1990s. Belarus, which retains a state-owned monopoly system, and Kyrgyzstan, where the German cigarette manufacturer Reemtsma has invested, would therefore appear to be exceptions, with Belarus more typical of the countries with transnational tobacco company investments and Kyrgyzstan more typical of the countries without such investments. In Belarus, however, the state tobacco manufacturer has only a 40% market share, with smuggled and counterfeit brands accounting for an additional 40% of this share. The importance the transnational tobacco companies attach to the illegal market in Belarus can be seen in the fact that, despite having little official market share,44 British American Tobacco and Philip Morris have the highest outdoor advertising budgets and the 9th and 10th highest television advertising budgets of all companies operating in that country.45 In Belarus, as in Ukraine and Russia, tobacco is the product most heavily advertised outdoors and the fourth most advertised product on television (there are now restrictions on television advertising in Ukraine and Russia).45,46 Thus, it appears that with the continuing (if so far fruitless) discussions of possible reunification with Russia, the transnational tobacco companies treat Belarus as an important extension of the Russian market.47
Kyrgyzstan differs from the other countries in which there have been transnational tobacco company investments in that these investments occurred later (in 1998) and one company, Reemtsma, achieved a manufacturing monopoly.44 However, Kyrgyzstan also differs from Belarus, Kazakhstan, Ukraine, and Russia in regard to its lower levels of development and industrialization and its larger rural and Muslim populations. Other potential explanations for the between-country differences observed cannot be excluded here, and such possibilities are explored in a separate article.48 Whatever reasons emerge, the rising rates of smoking among women and the younger ages of smoking initiation are cause for concern in all of these countries.
Meanwhile, the present findings, combined with earlier data on disease burden,1,37 confirm that high smoking rates among men continue unabated. Smoking among women in Armenia, Georgia, Kyrgyzstan, and Moldova remains relatively uncommon and does not appear to have increased significantly, as can be seen in rates among the younger relative to older generations and in limited comparisons with previous data. By contrast, smoking rates among women in Belarus, Ukraine, Kazakhstan, and Russia showed an increase from previous surveys, and age-specific rates suggest an ongoing increase in tobacco use among members of the younger generations. It is probably not a coincidence that these higher rates were observed in the countries with the most active transnational tobacco company presence.
Conclusions
Concerted and urgent efforts to improve tobacco control must be made throughout the former Soviet Union to curtail current smoking and prevent further rises in smoking among women. Such efforts will require enactment and effective enforcement of comprehensive tobacco control policies, including a total ban on tobacco advertising and sponsorship, adequate taxation of both imported and domestic cigarettes, controls on smuggling, and restrictions on smoking in public places. The barriers to achieving these goals are considerable given the powerful influence of transnational tobacco companies and the limited development of democracy and civil society groups in much of the region.21 The international community, cognizant of the role that international companies play in pushing the tobacco epidemic, should build on the work of the Open Society Institute (R. Bonnell, oral communication, September 2003) in strengthening the policy response to this threat.
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Acknowledgments |
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Note. The views expressed in this article are those of the authors and do not necessarily reflect the views of the European Community.
Human Participant Protection
This study was approved by the ethics committee of the London School of Hygiene and Tropical Medicine. Verbal informed consent was obtained from all study participants at the beginning of the interviews.
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Footnotes |
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Accepted for publication December 29, 2003.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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