Efza EvrengilUrban and Regional Planner

2 September 2010Istanbul

Tobacco consumption by sex and geographyEstimated number of smokers

(millions)Estimated smoking

prevalenceMen Women Total Men Women

High income countries 275 150 425 35% 22%Low & middle income countries 700 100 800 50% 9%World total 975 250 1225 47% 12%Source: Data gathered from Tobacco Atlas, 2009.

 • Approximately 250 million women and almost 1 billion men are daily smokers. Nearly 70 % of smokers live in med to low income countries.

• Male smoking prevalence is about 47 %. Female smoking prevalence is 12 %.

• While the rates for men have peaked and are now in slow decline, the epidemic among women is rising and will not reach its peak until well into this century.

• The WHO predicts that the prevalence among women worldwide will be 20 % by 2025. (Samet & Yoon, 2001).

Tobacco consumption among youth More than 17 % of youth aged 13-15 years use some form of tobacco

product (WHO, 2008). Everyday, some 80,000-100,000 young people around the world become

addicted to tobacco (WB, 1999) If current trends continue, 250 million of today’s children will die from

tobacco-related diseases (Murray CJ, Lopez AD, eds., 1996). Most people start smoking before the age of 18, and almost a quarter of

these smokers began smoking before the age of 10. (WHO, 2008). Global youth exposure to second hand smoke is very high (home + public

places).

Tobacco Mortality Currently, tobacco use kills more than 5 million people each

year. This number is expected to rise to 8.3 million by 2030. 70 % of these deaths will be in low and middle income countries (Mathers & Loncar, 2006).

Tobacco is projected to be the leading cause of death in 2020s. One in eight deaths.

In 2000, 990,000 women worldwide died of tobacco use. (Lopez, A.D., & Ezzati, 2003).

At present, this mortality is concentrated in high income countries, but if current trends continue, female prevalence and mortality will rapidly rise in the rest of the world.

Annual Tobacco Death Estimates (millions)

2000 2030

High income countries 2 ~3

Low & middle income countries ~2 ~7

World total 4 ~10

Source: adapted by CTLT from Peto, R. and Lopez, A. (2001).

Global Tobacco Consumption

About 6 trillion cigarettes are consumed worldwide annually. China’s tobacco market accounts for more than 1/3 of the world market

(representing 38 % of the cigarettes smoked globally).  Of the 3.5 trillion cigarettes smoked outside of China, about half are

smoked in ten countries: Russia, the US, Japan, Indonesia, Turkey, India, Brazil, Korea, and Italy.

Global tobacco epidemic is spreading among poorer geographies and social groups of the world.

Global cigarette consumption, 1880-2020 (billions of sticks)

Lopez, A.D., N.E. Callishaw N.E. and T. Piha, “A descriptive model of the cigarette epidemic in developed countries,” Tobacco Control, 1994, 3: 242.

Source: adapted from datasheets at http://tobaccoatlas.org/

Annual total cigarette consumption categories

2,000,000 + A500,000-

2,000,000 B200,000-500,000 C100,000-200,000 D50,000-100,000 E10,000-50,000 F

1-10,000 G

Per capita cigarette consuption categories

> 2500 A1500-2499 B500-1499 C

1-499 D

Smoking prevalence categories

> 60 % A50-60 % B40-50 % C30-40 % D20-40 % E10-20 % F5-10 % G< 5 % H

Source: adapted from data retrieved from http://tobaccoatlas.org/

Cigarette consumption in high population countries2007

population (15 and older

Cigarettes consumed,

2007 (millions) CATPer capita

consumption CAT

smoking prevalence (%)

male CAT female CAT1 CHINA 1,313,973,692 2,162,800 A 1,646 B 59.5 B 3.7 H

2 INDIA 1,095,351,964 108,000 D 99 D 27.6 E 1 H

3 USA 298,444,195 357,000 C 1,196 C 26.3 E 21.5 E

4 INDONESIA 245,452,710 239,000 C 974 C 62.1 A 4 H

5 BRAZIL 188,078,201 109,000 D 580 C 20.3 E 12.8 F

6 PAKISTAN 165,803,521 64,830 E 391 D 29.7 E 2.8 F

7 BANGLADESH 147,365,319 25,380 F 172 D 42.8 C 0.9 H

8 RUSSIAN FED 142,893,526 331,440 C 2,319 B 70.1 A 26.5 E

9 NIGERIA 131,859,689 13,600 F 103 D 9.1 G 0.2 H

10 JAPAN 127,463,597 258,500 C 2,028 B 44.3 C 14.3 F

11 MEXICO 107,449,494 50,540 E 470 D 36.9 D 12.4 F

12 PHILIPPINES 89,468,642 96,000 E 1,073 C 38.9 D 8.5 G

13 VIET NAM 84,402,939 74,860 E 887 C 42.9 C 2.2 H

14 GERMANY 82,422,285 92,700 E 1,125 C 37.4 D 25.8 E

15 EGYPT 78,886,974 85,335 E 1,082 C 24.5 E 0.9 H

16 ETHIOPIA 74,777,937 3,890 G 52 D 6.9 G 0.5 H

17 TURKEY 70,413,933 105,576 D 1,499 B 51.6 B 19.2 F

18 IRAN 68,688,407 52,500 E 764 C 24.0 E 1.9 H

19 THAILAND 64,631,573 41,000 F 634 C 37.1 D 3 H

20 FRANCE 62,752,118 54,945 E 876 C 36.6 D 26.7 E

21 CONGO DM 62,660,504 8,210 G 131 D 10.9 F 0.6 H

22 UNITED KINGDOM 60,609,136 47,900 F 790 C 36.7 D 34.7 D

23 ITALY 58,133,495 92,800 E 1,596 B 32.8 D 19.2 F

24 KOREA 48,846,804 84,650 E 1,733 B 53.3 B 5.7 G

25 MYANMAR 47,382,607 9,900 G 209 D 43.6 C 11.7 F

26 UKRAINE 46,710,802 118,000 D 2,526 A 63.8 A 22.7 E

Annual cigarette consumption, 2007 (millions of sticks)

Smoking prevalence (%), male - female

Cigarette consumption in high population countries

“a satisfied customer”Undated Marlboro adSource: tobacco.org, Pollay ads

“All the world enjoys a Marlboro. For everyone knows the special quality of this fine American cigarette. Marlboro’s full-flavored blend comes from the land that grows most the world’s best tobaccos. People everywhere have made it the best-selling cigarette in the famous Flip-Top box. For richer taste and a fine Selectrate filter try Marlboro. You got a lot to like, a lot to satisfy you.

America’s finest cigarettes have a quality all their own… from Philip Morris International.”

Locational shift of tobacco epidemic from rich to poor: Among regions and countries

Tobacco cultivation, manufacturing, and consumption have firmly moved from North to South / from high income to low income countries.

While the per capita consumption of tobacco fell by about 10% from 1970 to 1990 in developed countries, it increased by about 64% in developing countries during the same period. And per capita consumption has more than doubled in countries such as Haiti, Indonesia, Nepal, Senegal and Syria, while it has tripled in the Cameroon and China.

Specific regions of the world are of particular concern because of their enormous population and their position at an early stage of the tobacco epidemic.

The Asia Pacific Region is the fastest growing tobacco market in the world. Malaysia, Indonesia, Pakistan and Vietnam.

Studies have shown that smoking is becoming increasingly concentrated in lower socioeconomic groups nearly in all countries.

Smoking is more common among poor men (variously defined by income, education, occupation, or social class) than rich men nearly in all countries.

Study from Spain shows that smoking among women was rare until the 1960s. From 1968–72 onwards a converging pattern with men was observed. Women with a higher level of education started smoking before women with less education, but this pattern changed over the period 1978–82, with higher initiation rates among less-educated women during the last period studied (Schiaffino et al., 2003).

A Eurobarometer published in 2003 showed that the prevalence of smoking in 2002 was consistently higher among the unemployed (54%) and among manual workers (51%) in the EU15 (Eurobarometer, 2003).

A study published by the UK Department of Health revealed that only 10% of females and 12% of males in the highest socioeconomic group are smokers; in the lowest socioeconomic groups the corresponding figures are three-fold greater: 35% and 40% (UK Department of Health 1998).

In other European countries, the smoking prevalence is higher among the least qualified individuals, and this relationship has amplified between 1985 and 2000 (especially in Scandinavia, Germany, Italy, Spain) (European Commission, ASPECT Report, 2004).

A study of smoking prevalence among men in Chennai (India) in 1997 showed that the highest rate was found among the illiterate population (64%). This prevalence decreased by number of years of schooling, and declined to 21% among those with more than 12 years of schooling3— less than a third of illiterate men’s smoking prevalence (WHO, 2007).

Social shift from of tobacco epidemic from rich to poor: Within countries and social classes

Literature: “Vicious Cycle”

INDIVIDUALSHOUSEHOLDS

GOVERNMENTSNATIONAL ECONOMIES

Smoking related

costs +

reduced disposibl

e income

Poor people+ disadvantaged groups more likely to initiate smoking and become lifelong smokers

“Social inequalities are becoming more and more the prime determinant of tobacco consumption.”

“Smoking, poverty and inequality are inextricably linked.”

“Tobacco exacerbates poverty and is bad economics all round.”

Policy context : the Neoliberal Era Maximum privatization to open new fields of expansion of capital

Liquidation of national state properties Privatization of access to natural resources (water and petroleum) Erosion of social state and elimination of public services, particularly in education and

health Privatization of national tobacco monopolies

  Maximum capitalist transformation of agriculture and globalization of agribusiness

High productivity agriculture by a handful of farmers integrated into the global market Producing superprofits captured by multinational companies Destruction of peasant societies, pauperization

Tobacco production increased dramatically by 128 %, encouraged and financed by the tobacco industry, mostly in low income countries between 1975 and 1998.

World prices for tobacco fell by 37 % in real terms between 1985 and 2000. Four multinational companies dominate and regulate cultivation and trade of

unmanufactured tobacco. Tobacco growing is exceptionally labor intensive and relies heavily on the labor of

women and children globally. Underpaid and often unpaid family labor of small tobacco farmers is the key factor that

ensures large profits for multinationals. Child labor continues to deprive children of their basic rights. Children provide

‘adjustable labor’ at peak periods and sometimes contribute to a third of labor input. Not coincidentally, regions in which cultivated tobacco occupies a significant amount of

land are also often pockets of poverty.

 

Maximum deregulation and liberalization of trade WB, IMF and WTO pushed and governments welcomed reductions in tariff and non-

tariff barriers to trade to facilitate further expansion of capital on a global scale Growing concentration of power in the hands of transnationals Liberalization of movement of capital, increased foreign direct investment Globalization of markets, significant transnational transfer of profits Increased rate of return for capital States forbidden in principle from interfering in economic affairs. The function of

State is reduced to narrow policing Big Western tobacco companies acquired a multinational management and

capital structure. Between 1991 and 2001 over 140 mergers and acquisitions took place.

 The global tobacco market increasingly concentrated in the hands of a very few companies.

These companies adopted aggressive strategies to expand their global trade and achieve market penetration in the markets of low and middle income countries and newly emerging markets:

Latin America in the 1960s

Newly industrialized economies of Asia in the 1980s

Africa, China and Eastern Europe in the 1990s Women and youth have become the main targets in these markets. Deregulation and trade and DFI liberalization resulted in increased supply and

lower prices => increased tobacco consumption. Creation of weak regulatory mechanisms.

Policy context: the Neoliberal Era

Recent mergers/acquisitions

Acquired Acquired by Rothmans (International, 1999)Ente Tabacchi Italiani (Italy 2003-4)Cigarette component of Skandinavisk Tobaks (2008) British American TobaccoTobacco component of Tekel (Turkey, 2008)Bentoel (Indonesia, 2009) Tobaccor (Africa, 2001)Reemstsma (International, 2004) Imperial TobaccoCommonwealth Brands (USA, 2006)Altadis (International, 2008) Ligett Ducat (to Gallaher, 2000)Austria Tabac (to Gallaher, 2003) Japan TobaccoGallaher (International, 2007)International component of RJ Reynolds (2001) Brown & Williamson (USA, 2004) Reynolds American Altria spins off PMI (2008)Sampoerna (Indonesia, 2006)Rothmans, Benson & Hedges (Canada, 2008) Philip Morris InternationalLakson (Pakistan, 2008)

Source: Physicians for a Smokefree Canada, 2009.

World tobacco market pie, 2008

Source: Adapted from data from Physicians for a Smokefree Canada, 2009.

Neoliberal policies resulted in increased poverty and increased tobacco consumptionWHO and WB economists:

“The potential health consequences of trade and investment liberalizations are higher rates of tobacco related deaths and disability.”

“Econometric research supports the premise that trade openness lead to higher tobacco consumption.”

“Increased levels of FDI also lead to higher rates of cigarette consumption.”

(Bettcher et al, WHO, 2001)

Undated Camel adSource: Tobacco.org, Pollay ads

ConsequencesDemise of the neoliberal era?

(Economic crises, popular discontent, emergence of dissident governments)

Renewed interest on reducing poverty => Millennium Goals (completely hypocritical, based on tenets of neoliberal economy)

Search for national and international regulatory frameworks => FCTC (binding, required to be ratified by each nation, recognizes legitimacy of state intervention and international cooperation). FCTC is now ratified by 169 nations, but not by USA, Indonesia, Argentina…

ChallengesImlementing comprehensive tobacco control policies Raising tabocco taxes and thus making tobacco products less

affordable remains to be the best remedy to get out of the vicious cycle of poverty and tobacco use.

Tax revenues need to be diverted to TC to benefit the poor and to fight health inequalities.

Other critical TC policies: Enactment and enforcement of 100% smokefree indoor

workplaces and public spaces + promotion of smokefree homes + dissemination of messages of smokefree environments for all

Enforcement of sales restrictions and comprehensive bans on tobacco APS

Implementation of large, visible, and regularly changing health warnings and messages on tobacco product packages

Increasing availability and access to treatment services for tobacco dependence + development of gender specific treatment.

Increasing public awareness and approval of effective tobacco control policies through education and communication campaigns reaching wide segments of population.

ChallengesResources and political commitmentResources applied to implement this globalized public health

instrument remain modest.Significant transnational transfer of tobacco revenues needed

to support tobacco control efforts at national and international levels.

Governments, political parties need to recognize the burden of tobacco epidemic and commit themselves to tobacco control policies.

Huge health care infrastructure building and treatment costs of tobacco-related diseases expected to rise in low and middle income countries.

Tobacco industry assaultsDirect and indirect legal challenges through front groups.Traditional lobbying + use of new technologies to circumvent

tobacco control legislation.Trans border internet advertising and sales + industry

complicity in illicit tobacco trade.

The Global Youth Tobacco Survey canvassed 400 000 students aged 13-15 in all WHO regions: There are fewer significant gender differences in smoking as time goes by, indicating that the gender gap appears to be closing and the future of tobacco epidemic among women may eventually involve more than the actual estimates (WHO, 2007).

Gendered marketing, messaging and imagery linked with health, upward mobility, Western lifestyles and positive wellbeing targeting women, and independence, coming of age, hedonism, freedom and comfort messages and imagery linked with sports, fame, and success targeting adolescents are being used in low and middle income countries by transnational tobacco firms to feed the spread of tobacco use.

The tobacco industry admits that the largest untapped market for them is the female market in low income and middle income countries.

In western countries there has been substantial decline in male smoking prevalence, but the decline among women has been slower (Norway, Sweden), indicating persistence of smoking habits especially among poor women.

Increasing evidence suggests that smoking careers are shaped by a continuity of disadvantage from childhood through adolescence into adulthood. Poor peope make poor quitters. Study in France suggests poor smokers may be less sensitive to cigarette price increases (Peretti-Watel, 2008).

Challenges

a mini slide show

“Taste Success”Rothmans billboard ad in Logos, Nigeria 2001Source: TFK, Tobacco Ads Gallery

Gigantic Winner and Marlboro ads, billboards in South East Asia, location unknown, undatedSource: Tobacco.org, Pollay ads

“Art and Literature”, Benson & Hedges billboard ad in Bangladesh, undatedSource: TFK, Tobacco Ads Gallery

Salem billboard ad Malesia, 2001Source: TFK, Tobacco Ads Gallery

Street scene from Hong Kong, 1992Source: Tobacco.org, Pollay ads

Entrance to the International Airport, Asuncion, Paraguay, 2001Source: TFK, Tobacco Ads Gallery

Branding of POS, Turkey, undatedSource: Tobacco.org, Pollay ads

Branding of POS, Argentina, undatedSource: TFK, Tobacco Ads Gallery

Child with skateboard, USA, undated Source: tobacco.org, Pollay ads