1.13 International comparisons of prevalence of smoking

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An estimated 1.25 billion adults worldwide are smokers,127 and international findings that 17% of young teenage school students are also current tobacco users (in one form or another) confirm that tobacco-caused illness and death will continue for many decades to come.128

1.13.1 International comparisons of adult smoking prevalence

In general, the prevalence of smoking is declining in industrialised countries in Northern and Western Europe, North America and the Western Pacific region, and is on the increase in some countries in Asia, South America and Africa.129 As global patterns in tobacco use change, the burden of death can be expected to transfer from the developed world to less wealthy countries. About 80% of the world's smokers now live in low and middle income countries, at least in part due to a lack of adequate tobacco controls.130 The marketing practices of the tobacco industry in developing countries are particularly aggressive,127, 129, 131 and the international tobacco industry's efforts to subvert tobacco control activities in developing countries are well-documented.132 Although the tobacco industry has publicly acknowledged the health consequences of smoking[10] and is required to conform to stringent regulation in more privileged nations,129 there is ample evidence that it deliberately exploits the comparative lack of controls in less developed countries.132, 133 As more countries ratify the Framework Convention on Tobacco Control, an initiative by the World Health Organization to counter the globalisation of the tobacco epidemic134 (see Chapter 18) it is to be hoped that these activities will be effectively curbed.

A paradigm illustrating the typical progression of tobacco use worldwide, first proposed by Lopez et al61 and later adopted by the World Health Organization,129 is reproduced here (Figure 1.6). Many (but not all) countries' experiences of patterns of tobacco use fit this model.

Stage one of the model is marked by a low smoking prevalence (below 20%), generally limited to males and accompanied by little evident increase in tobacco-caused chronic illness. Countries at stage one have not yet become major consumers in the global tobacco economy, but represent untapped potential for the tobacco industry. Some countries in sub-Saharan Africa fit into this stage in the model.129 The importance of tobacco farming in some countries in the region (for example Zimbabwe and Malawi) may act as a deterrent to the introduction of tobacco control policies. Zimbabwe is among the largest producers of tobacco in the world and is a major exporter; and concerns about the health consequences of tobacco use are not high on the national agenda.135

In stage two of the paradigm, male prevalence of smoking has soared to more than 50% in men, and women's smoking rates are now increasing. Uptake of smoking is occurring at an earlier age, and although there is now evidence of increased lung cancer and other chronic illness due to smoking among men, public and political understanding of and support for tobacco control initiatives is still not widespread. Countries that fit into this transitional stage include Japan, some nations within the South-East Asian, Latin American and North African regions, and to a lesser extent, China. (The case of China is discussed further below).129

Stage three of the epidemic has been reached when smoking prevalence peaks and begins to decline in both sexes; although deaths caused by smoking continue to increase because of earlier high smoking rates. Health education programs are better developed, smoking becomes less accepted among the more educated groups of society, and the climate is increasingly conducive to the introduction of tobacco control policies. Certain countries within Eastern and Southern Europe and Latin America are at this point on the continuum.129

Evolution into stage four is marked by a continued distinct but gradual downturn in smoking prevalence among both males and females. Male deaths from smoking begin to decline, but female death rates continue to rise, reflecting earlier smoking patterns. Parts of Western Europe, the United Kingdom, the USA, Canada, New Zealand and Australia are at various points on the continuum in the fourth stage of the tobacco epidemic.129 However, comprehensive and continually monitored public health strategies remain critical to maintain and reinforce declines in smoking prevalence.129

As noted above, there are some countries for which the paradigm devised by Lopez et al in Figure 1.6 does not fit. This is especially so in nations in which female smoking rates have not shown a pattern of steady increase in Stage II, despite high prevalence among males, most likely due to social or cultural constraints. For example men in China and Indonesia have maintained high rates of smoking for many years, while female prevalence has remained in single digits. However the WHO model described above provides a useful framework into which many countries can be placed, and may enable countries currently at an earlier stage in the paradigm to recognise their situation, learn from international experience and introduce strong public health measures that will reduce the impact of tobacco on their population. Singapore provides a successful example of early intervention. In the early 1970s, while at stage two of the model, the Singaporean government initiated a series of tobacco control measures that capped smoking prevalence at a relatively low level, effectively averting the later stages of the epidemic. Thousands of tobacco-caused deaths in Singapore have been prevented as a result of this early, decisive action.61

Tables 1.14 and 1.15 present statistics on smoking prevalence from a number of different countries. Table 1.14 shows prevalence data collected by the OECD (Organisation for Economic Co-operation and Development) of its 30 member countries,136 and the data in Table 1.15 are taken from a wide variety of sources compiled by The Tobacco Atlas (Second Edition).127 These tables are provided in order to provide a general global overview. It is important to note that data sets between countries are not directly comparable, due to differences in sampling and definitions, and that overall prevalence figures such as those provided by the table may mask higher smoking levels among particular sub-groups of the population. Further, studies which only take into account the smoking of manufactured cigarettes will underestimate tobacco use in countries where tobacco is widely used in other forms, such as in pipes, hand-rolled leaves or as chewing tobacco. This is a key consideration in countries where alternative methods of tobacco use are prevalent, such as in Sweden137 and throughout much of Southern and South-East Asia.113, 138 The interested reader is referred in the first instance to the primary sources, which explain the parameters of each study.

The global impact of death and disease caused by tobacco smoking is discussed in Chapter 3, Section 3.34 .

1.13.2 International comparisons of smoking prevalence in children

The Global Youth Tobacco Survey (GYTS) is a joint project of the World Health Organization, the US Centres for Disease Control and Prevention, the Canadian Public Health Association and most WHO member states. A schools-based survey of teenagers aged 13–15, the GYTS has enabled consistent data collection from 395 sites encompassing 131 countries, plus the Gaza Strip and the West Bank.128 Table 1.16 summarises some of the available data by WHO region, for the years 1999–2005.

Overall, 17% of surveyed students had used some form of tobacco product in the 30 days prior to the survey. The differences between boys' and girls' smoking rates were statistically significant in the eastern Mediterranean, South Asia and Western Pacific regions. In many countries the difference between boys' and girls' smoking rates was narrower than expected, reflecting increased uptake of smoking in girls.128

The GYTS has also reported on susceptibility to taking up smoking, by asking never-smokers whether they would smoke a cigarette if it were offered by their best friend, and whether they thought they might smoke a cigarette within the next year. By these measures, 18% of respondents were susceptible to commencing smoking within the next year. Teenagers in the European region had the highest susceptibility (31%), and teenagers in the Western Pacific region the lowest (8%).128

National data have also been reported for 2006 from New Zealand, Canada, Ireland, and England, and from the USA for 2007. These data are of interest since these countries have adopted, to a greater or lesser extent, tobacco control measures which are similar to those operating in Australia. Key findings from some international surveys are reported briefly here and interested readers should refer to the primary sources for further information. Due to methodological differences, it should be noted that these data are not directly comparable with Australian data or with each other.

• In New Zealand in 2006, a survey of Year 10 students (aged 14–15) found that 14% of respondents were smokers. Eleven percent of boys and 18% of girls said that they smoked on a daily, weekly or monthly basis. Eight percent of students in Year 10 smoked on a daily basis (7% of boys and 10% of girls).139
• Canadian research shows that in 2006, 15% of teenagers aged 15–19 smoked on a daily or occasional basis. Sixteen percent of males in this age bracket, and 14% of females were daily or occasional smokers. Nine percent of teenagers aged 15–19 were daily smokers (10% of males and 8% of females).140
• Ireland's Health Behaviour in School-aged Children Survey 2006 reported that 15% of 10–17 year olds were current smokers.141
• A schools-based study in England showed that in 2006, 9% of 11–15 year olds reported that they usually smoked at least one cigarette a week (7% of boys and 10% of girls). Prevalence of smoking increased with age, with 16% of males and 24% of females reporting weekly smoking by age 15.142
• The Monitoring the Future study from the USA has reported that in 2007, 7% percent of students in 8th Grade, 14% of 10th Graders and 22% of 12th Graders had smoked a cigarette in the 30 days prior to survey. Daily smoking was reported by 3% of 8th Grade students, 7% of 10th Graders, and 12% of 12th Grade students.143