The developing world stands to bear the health costs and economic burden of ongoing massive increases in tobacco use and tobacco-related death.



In 1996, an article in the British Medical Bulletin predicted that "if not prevented, there will be an appalling future increase in tobacco-related disease, disability and death" in developing countries. The authors cited, among other reasons, "intensive and ruthless marketing by multinational tobacco companies" as the greatest impetus for tobacco's rise in the developing world. At the time, 3 million deaths worldwide were attributable to tobacco. The study's authors predicted that by 2025, 10 million deaths per year would be attributable to tobacco use. And not just that, but that 7 million of those deaths would be in third-world countries.

Despite moderate decreases in smoking in the United States, the pervasive influence of cigarette manufacturers continues in the developing world in such a way that we appear on-pace to meet that prediction. The recently released Global Adult Tobacco Survey (GATS) is the largest of its kind, having surveyed 14 low and middle-income countries -- Bangladesh, Brazil, China, Egypt, India, Mexico, Philippines, Poland, Russia, Thailand, Turkey, Ukraine, Uruguay, Vietnam -- and compared this to data from the U.S. and the U.K. Overall, the data account for 3 billion people over the age of 15 and represent 852 million tobacco users. 

Manufactured cigarettes are, by far, the most widely used form of tobacco consumption in the countries surveyed by the GATS. Accounting for 82 percent of tobacco consumption, they drastically overshadow regional smoking products like cigars, cigarillos, pipes, waterpipes, kreteks, bidis, and papirosy. They have failed to gain a majority only in India, where smokeless tobacco is favored. Their prevalence is easy to account for -- as the authors point out, "These products are technologically designed to mask harshness, provide particular taste sensations, and increase nicotine delivery."

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Global Adult Tobacco Survey

Manufactured cigarettes are notoriously associated with increasing smoking among females. Even though tobacco use is disproportionally found in men (48.6% percent of men in the low and middle-income countries smoked, as opposed to just 11.6 percent of women), women are increasingly starting to smoke at younger ages. In the 25-34 age bracket, the mean age of initiation was similar for both sexes. 

As smoking becomes more common for women in these countries, demographics may begin to reflect those seen in the U.K. and the U.S. Although the rates of male smoking in these two countries are low, the rates for women are among the highest.

As these trends continue, the burden of the worldwide deaths (along with the economic and healthcare costs) will fall increasingly on low and middle-income countries such as those surveyed. This represents an inversion from the current state, in which high-income nations shoulder most of the costs of tobacco-related disease. 

Not only are people starting to smoke more -- particularly in Russia, Ukraine, and Turkey -- but quit rates are also low. They are less than 20 percent in China, India, Egypt, Russia, and Bangladesh. In commentary that accompanies the survey, it is pointed out that in many low-income countries, "for every 9,100 US dollars received in tobacco taxes, only one dollar was spent on tobacco control." Quit rates are noticeably higher in countries with programs in place for discouraging tobacco use and helping with quitting, such as the U.S., the U.K., Brazil, and Uruguay.

As the world looks to countries as models for tobacco use, Uruguay deserves note. It was included in GATS precisely because of its stringent anti-tobacco policies, including mandated graphic labels that take up 80 percent of cigarette packaging, sales tax increases, and bans on tobacco advertising and on indoor smoking in public places. Earlier this month, the International Tobacco Control Policy Evaluation Project (ITC) released a report indicating that the prevalence of tobacco use in Uruguay has decreased by 25 percent over three years.

Among other promising data, 70 percent of Uruguay's smokers expressed regret for every having taken up smoking, and in the five-year period covered by the survey, over two-thirds of smokers at least attempted to quit. Positive health changes are already being seen, and may in part be attributed to these policies. The ITC found a 22 percent reduction in the rate of hospital admissions for heart attacks and a 90 percent decrease in air contamination in enclosed public spaces in the year after they were enacted.

These numbers indicate that while the forecast is grim -- the GATS predicts that at this rate we stand to see one billion tobacco-related deaths during the twenty-first century -- change is possible.