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Respiratory medicine and the Third World

Tobacco and the Third World

John Crofton

The backgroundAll readers of Thorax will be aware that inindustrialised countries tobacco is far the mostimportant preventable cause of disease anddeath.` Although many countries have beenslow to tackle this menace, public and politicalopinion is gathering momentum both nation-ally and internationally.

In 1979 a World Health Organisationexpert committee6 warned that, unless therewas strong and effective government action,the smoking epidemic would soon spreadfrom the industrialised countries to theeconomically developing world. This wouldfurther exacerbate the already grim healthproblems arising from malnutrition and com-municable disease. By 1983 a further WHOexpert committee reported that this pessimis-tic prediction was already being fulfilled.8

Tobacco consumption and prevalence ofsmokingTRENDS IN TOBACCO CONSUMPTIONData collected by WHO showed that,although tobacco consumption fell by 1 lOo ayear in developed countries during 1976-80, itrose by 210"0 in the developing world.8 Globalconsumption rose by 7 1°n between 1970 and1985 (fig 1). Isome industriz

+7.10%

WORLD

90/0

USA

- 25%

UKFigure I Global changes in czgarette consumptio?

United Kingdom and United States (fig 1),but formidable rises occurred in Asia, Africa,and Latin America,9 albeit from lowerbaselines. Examples from individual countriesinclude increases in consumption of manufac-tured cigarettes between 1970 and 1980 of32( in Kenya, 40%i in India, and no less than625',, in Pakistan."'The trends continue. In 1988 consumption

of cigarettes fell by 1 00 in the developed (non-communist) countries but rose by 2 30, in thedeveloping world. China alone consumed29 30, of the world total of 1 5 trillion (1 5 x10'") cigarettes."

PREVALENCE OF SMOKINGFrom these figures it is clear that there hasbeen a great increase in smoking in manydeveloping countries, at a time when smokinghas fallen in some of the developed countries.Half or more of the men smoke in a muchhigher proportion of developing than devel-oped countries (fig 2) 12Examples from selected developing coun-

tries around the world are shown in figures 3and 4; in figure 3 the prevalence figures arecompared with those from some representa-tive industrialised countries.

?here were substantial falls in Male smoking rates are now higher in manyalised countries, notably the developing countries (especially in Asia and

the Pacific) than in many industrialised coun-

.420/. tries (see figs 3 and 4). Nevertheless, smokers,owing to poverty, often smoke fewer manufac-tured cigarettes on average in a developingcountry than in richer countries. This is par-

ticularly true for tropical Africa and forwomen. But in some countries there is heavy

22+.2 4% smoking of locally prepared cigarettes. For

+22 instance, adult smokers in India in 1977

smoked on average only 190 manufacturedcigarettes, compared with 2910 in the UK.'3In the same year, however, the consumptionof "bidis" (locally made cigarettes) was 1500pieces per adult smoker. Bidis have a high tar,nicotine, and carbon monoxide content, and

are probably more dangerous.'3ASIA LATIN AFRICA Among the limited figures available for

tropical' Africa are a smoking prevalence ofAMERICA 64°,, in Sudanese doctors, 35°O in Sudanese

male medical students (only 2 ",, in thewomen),'4 and 580o in non-medical staff at themain teaching hospital in Nairobi.'5 A surveyin 1976 in Nigeria showed a smokingprevalence of 40)( in boys and 80w, in girls in

secondary schools"; a recent figure for olderprimary school children in Nairobi was 35(9

n 1970-85. Source: Jacobson et al.9 (PJ Wangai, personal communication).

Thorax 1990;45:164-169

Address for reprint requests:Sir John Crofton,13 Spylaw Bank Road,Edinburgh EH13 OJW.

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In some developing nations, as in manydeveloped countries, teenage girls have a

higher smoking rate than boys; these countriesinclude Brazil, Chile, Papua New Guinea, andUruguay.20

ECONOMICALLYDEVELOPINGCOUNTRIES 28B/

INDUSTRIALISEDCOUNTRIES

37COUNTRIES

29COUNTRIES

Figure 2 Proportion of economically developing and of industralised countries in whichhalf or more of men smoke (partially industralised countries-for example, Sin apore,Republic of Korea-classified with "developing"). Based on datafrom WHO' (somefigures derivedfrom limited national surveys); most surveys conducted during 1981-6.

Smoking in womenDeveloping countries vary widely in thesmoking rate for women (figs 3 and 4). Insome it is much lower than in men (for exam-ple, India, Indonesia, China, Malaysia, Tun-isia, and Nigeria); in others it approaches themale rate (for example, Papua New Guinea,Nepal, Uruguay, and Brazil). In some coun-

tries the rate is rising in women, among whomsmoking may be regarded as an indication ofliberation, modernity, and sophistication. Therate has reached 27% in Tianjin, a Chineseindustrial city, compared with only 8% in a

sample survey for the whole of China.'7 Asurvey in Nigerian colleges of higher educa-tion found the highest female rate (over 50%)in schoolteachers in training."8 The prevalencein "women at medical school" in Nigeria was

said to be 72% as early as 1976.16 In manyparts of India the female smoking rate is lowbut the traditional tobacco chewing rate ishigh, resulting in a formidable prevalence ofmouth cancer, the most common cancer inIndia.'9

Figure 3 Smokingprevalence (00) in adults(nale andfemale) inselected industrialised andAsian and Pacificcountries. Originalfifuresfrom WHO (1988)' -see

figure 2for provisos aboutaccuracy.

CANADA

USA

UK

AUSTRALIA

GREECE

SWEDEN

NORWAY

USSR

FRANCE

ITALY

POLAND

JAPAN

_~ MALE

IZIJFEMALE

INDUSTRIALISED COUNTRIES

Smoking related diseaseLUNG CANCERAs 85-90% of lung cancer is due to smoking,its incidence in different societies could be a

useful marker of the ill effects of tobacco.There are, of course, disadvantages in usingthis marker: (a) accurate mortality data are notavailable in many developing countries; (b)with the latent period of 20 years or more

between initiation of smoking and the devel-opment of cancer it is a relatively late effect;(c) the shorter life expectancy in developingcountries means that fewer people survive intothe cancer age2"; (d) diagnosis is likely to beless accurate in many developing countries.

Nevertheless, using cancer registeries whereavailable and indirect methods where neces-

sary, Parkin and his colleagues from the Inter-national Agency for Research in Cancerattempted to calculate the worldwide fre-quency of lung cancer in 1980.22 On the basisof this work Stanley and Stjernsward23 haveestimated the relative numbers of patientswith lung cancer in developed and developingregions of the world. Their results are sum-

marised in figure 5. Already over 30% of allcases of lung cancer seem to be occurring inthe developing regions. Surprisingly, this per-centage is higher for women than for men,though the actual numbers are, of course,much lower in women. This may be becausein some regions of the world there appears tobe an unidentified factor, in addition to smok-ing, that causes lung cancer in women.24Lung cancer is already the most common

cancer in males in Southern Africa, SouthEastern Asia, Western Asia, and Micronesiaand Polynesia.22 Parkin, in a later paper,25 hasgiven some further figures for developingcountries. The lung cancer incidence forChinese men in Singapore is similar to thatfor United States white men, and the inci-

HONG KONG 23

PAKISTAN 4

INDIA 52

MALAYSIA 56

THAILAND 59

CHINA 62

REPUBLIC OF 69KOREABANGLADESH 70

INDONESIA 75

PHILIPPINES 78

NEPAL 79

FIJI _PAPUA 85NEW GUINEA I0

ASIAN/ PACIFIC COUNTRIES

Tobacco and the Third World

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Crofton

Figure 4 Smokinlgprevalence (,") i.n adults/ mtiale andjfemnaleJ inselected countries in Africaanid the Middle East andiln Latin America.Original figures fromiWHO (1988) 12 seefiguire 2for provisos aboutaccuLLracv.

A

CoTE D IVOIRE

ETHIOPIA

UGANDA

EGYPT

ZAMBIA

SENEGAL

KUWAIT

NIGERIA

TUNISIA

-~~MALEI I FEMALE

COUNTRIES IN AFRICA/MIDDLE EA

dence among middle aged men in Shanghai issimilar to that for men of the same age in theUK. Important increases have been recordedin men in Bombay, Pakistan, and Kuwait. InLatin America there have been increases in

both sexes in Brazil and Chile, though in thelatter some of the increase could have beendue to better diagnosis. In tropical Africa therates are still low. Lung cancer accounted foronly 1 -1") of all cancers diagnosed in Ibadan,Nigeria, in 1960-9 and for only 2 50, in 1975-6. No increase has yet been recorded in a longterm series in Uganda, or in Bulawayo, Zim-babwe. Although smoking prevalence has in-creased in many of these African countries,the increases have been relatively recent and,because of poverty, often only a few cigarettesa day are smoked. Parkin estimated that in1980 lung cancer accounted for only 1 5°0 ofall cancers in "Africa" (presumably tropicalAfrica).)

CHRONIC BRONCHITIS AND EMPHYSEMA

Chronic bronchitis and emphysema (with the

Figure 5 Percentagedistribution betweendeveloping and developedregions of new cases of lungcancer in 1980: males,females and the sexes

combined. FiguresfromParkin et al 1988 2;Stanley and Sternswad1989.2?

TOTAL CASES 660 500

DEVELOPEDREGIONS

513 600

30*1.

DEVELOPING-REGIONS

LATIN AMERICAN COUNTRIES

plethora of synonyms-chronic obstructiveairways disease etc) is also closely related totobacco smoking,26 though there are othercausative factors.27 30 In a newly smoking com-

munity the increase in the prevalence of bron-chitis will probably appear earlier than theincrease in lung cancer mortality.Community surveys, some of them carried

out 10 years or more ago, have already shownrelatively high prevalence rates for chronicbronchitis in India, 31-33 China, 34 Papua NewGuinea,35 Nepal,38 Malaysia,39 rural Egypt,"and the Caribbean.4" Most of these surveysfound a correlation between smoking andmorbidity, though in some surveys the rate

for chronic bronchitis in non-smokers appearsto be higher than in most surveys in

developed countries. For instance, in thehighlands of Papua New Guinea the veryprevalent chronic lung disease seems to becommon in non-smokers; the main factorappears to be intense exposure to domesticsmoke in chimneyless houses.42As some of the work outlined above was

done several years ago, we need up to daterepeat surveys to measure the change inprevalence of chronic bronchitis in countrieswhere smoking is increasing. Data fromtropical Africa are particularly sparse.43

Causes of the Third World epidemicTHE TOBACCO COMPANIES

In some developing countries, such as India,smoking locally made cigarettes (bidis) is a

long established habit, and the major reason

for the current explosion of smoking in theThird World has been the marketing drive ofthe multinational tobacco companies based inBritain and the United Stated.44 6 With the

146 900 shrinking markets in the developed world, thecompanies have conducted a monstrouspromotional campaign in many developingcountries.47 48 They have used their vast finan-

|35 cial resources to launch major advertisingcampaigns, to sponsor popular sportingevents, and to win over politicians and

FEMALESdecision makers. They have used threats of

FEMALES American sanctions to break into the markets

PERU

GUATEMALA

MEXICO

URUGUAY

GUYANA

CHILE

VENEZUELA

ARGENTINA

BRAZIL

158159

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Tobacco and the Third World

of Taiwan and South Korea, and to asserttheir right to intensive commercial promotion,previously forbidden in those countries. Nowthey are trying to do the same in Thailand.Advertisements for Western cigarettes arealready seen in Chinese cities, where advertis-ing is supposed to be forbidden. In many ofthese countries the advertising seeks to showcigarette smoking as smart, sophisticated, andWestern. It aims in the first place to recruitopinion leaders, or future opinion leaders suchas university students.

THE FEMALE MARKETSmoking rates in women at present are low inmany countries. The tobacco industry is clearlytargeting its advertising at this potential growthmarket worldwide.949 The industry claims thatadvertising is aimed only at persuading peopleto switch brands. But it launched an intensiveadvertising campaign orientated towardswomen in Hong Kong, where only a tinypercentage of women smoke; the promotionalcosts could have paid off only if a major newmarket among women was created.

CHILDRENWhen smoking is introduced into a country ittends at first to be taken up by adults, oftenyoung adults. Only later do children seek tocopy the adult habit. The emulation is, ofcourse, stimulated by advertisements picturingsmoking as a glamorous activity of successfuladults. In Singapore and Tahiti, as in severalindustrialised countries, total bans on tobaccopromotion seem to have made an importantcontribution to a decline in smoking rates inchildren.50

Responses to the ChallengeWORLD HEALTH ORGANISATIONSince the publication of the WHO expertcommittee reports drawing attention to thethreat,68 the climate of informed world opinionhas gradually changed. The World HealthAssembly has passed resolutions urging thatthe problem should be given higher priority.But for some time world action hardly matchedworld rhetoric. WHO had serious financialdifficulties and devoted relatively small resour-ces to this field. Nevertheless, its expert re-ports"' " were very influential, it collectedmany international data,'252 and it producedsome useful guides.5'56 After the success of"National No Smoking Days" in some coun-tries, WHO initiated the first "World NoTobacco Day" in 1988. This had a majorimpact in many countries, including China,Philippines, South Korea, India, Pakistan,Bangladesh, and countries in the EasternMediterranean. Among the WHO regions,WHO Europe has already launched a compre-hensive and enthusiastic programme. Pro-grammes are in preparation in the Americanand the Eastern Mediterranean regions. Apreparatory meeting is planned in the WesternPacific Region. The South East Asian Regionheld a workshop some years ago but seems tohave no immediate plans for a formal pro-

gramme. The African Region has so far giventhis problem low priority.As a result of much international pressure,

the Director General of WHO assembled anexpert group in March 1988 to propose anexpanded five year programme for WHO.Since then more central WHO resources havebeen allocated to this work. Additional extra-budgetary funds have been obtained, thoughthe total available is still meagre by tobaccocompany standards. There has been activefurther planning. Practical proposals were putto an expert advisory group, including repre-sentatives of intemational non-governmentalorganisations, in November 1989. The pro-gramme was formally launched in January1990. The prospects for a major global WHOdrive against tobacco now seem much morehopeful.

NON-GOVERNMENTAL ORGANISATIONSSeveral intemational non-governmentalorganisations have been very active. The Inter-national Union against Cancer (usually knownby its French initials UICC) has for many yearsrun an excellent programme, supported bygenerous donations from Norway. It has heldmany useful regional workshops in Asia andAfrica, some jointly with WHO. Under thesame aegis, and in cooperation with the Inter-national Organisation of Consumers' Union,the American Cancer Society has helped to setup an active network for coordinating action bynon-governmental organisations in LatinAmerica.57 This has initiated a series of suc-cessful regional workshops. UICC has publi-shed several valuable handbooks.5"'The International Union against Tuber-

culosis and Lung Disease formed a Tobaccoand Health Committee in 1984. Since then allthe Union's global and regional conferenceshave been non-smoking and have featured aplenary session on the problem of smoking;these have included conferences in Kuwait,Turkey, Sudan, Tunisia, Senegal, Nepal, Pak-istan, and Singapore. A booklet,6" summarisingthe evidence and suggesting how they mighthelp, was sent to the several thousandindividual IUATLD members (mostly doc-tors) in 113 countries and to all the affiliatednational organisations. It was accompanied bya leaflet aimed at decision makers,62 issuedjointly with UICC. This was designed so that itcould be modified for an individual country. Sofar it has been translated and adapted for use inNorway, Italy, Hong Kong, China, India, andprobably elsewhere. An information booklet onrelevant IUATLD and world tobacco activitiesis sent annually to members and affiliatedorganisations. To stimulate the interest offuture doctors and their teachers, a survey ofthe smoking habits, knowledge, and attitudesof medical students has been conducted insome 40 countries, including many in theThird World. A preliminary analysis of resultsfrom 14 European countries63 has suggestedmajor deficiencies in medical education in thiscontext; the results from developing countriesmay prove to be even more alarming. A similarglobal study among nurses is at present underdiscussion.

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The International Organisation of Con-sumers Unions has decided to give highpriority to tobacco's threat to consumers. Thisis proving a formidable campaigning body. Ithas appropriately called its campaigning wingAGHAST: Action Group to Halt Advertisingand Sponsorship of Tobacco. It is concentrat-ing on the Third World; the coordinatingcentre is in Penang, Malaysia. The organisationhas held useful campaigning workshops in Asiaas well as Latin America and Africa, and hassuccessfully lobbied countries attending theWorld Health Assembly. It produces valuablesupporting publications""" as well as cir-culating regular updates on the misdoings ofthe tobacco industry.

Several new international initiatives intobacco control are soon to be launched. Theywill link existing data bases and form a networkto provide information, together withmaterials, training, and expert advice for anti-tobacco campaigners throughout the world,especially in developing countries.Some other international non-governmental

organisations have passed pious resolutionsand recommended appropriate action, but haveso far made little real effort to get their recom-mendations implemented. As tobacco is amajor preventable cause of cardiovascular dis-ease it is particularly encouraging to learn thatthe International Society and Federation ofCardiology is now considering setting up anexpert group to stimulate effective action. So isthe International Union for Health Education.

WORLD COOPERATIONStemming from a "Summit of World SmokingControl Leaders" in Washington in 1985,organised by the American Cancer Society,there has been useful ongoing cooperationbetween the active international non-govern-mental organisations, and between these agen-cies and WHO. The leaders ofthe non-govern-mental organisations keep in touch regularly.There have been joint workshops or sessions indifferent parts of the world. Several inter-national non-governmental organisations madeimportant contributions to China's first inter-national conference on smoking and health inTianjin in 1987, which was followed by afurther conference in Shanghai. Represen-tatives of relevant non-governmental organisa-tions participated in the meeting of the WHOTechnical Advisory Group in Geneva inNovember 1989. It is present WHO policy tocoordinate its work with that of these inter-national NGOs. The Seventh World Con-ference on Tobacco and Health, to be held inPerth, Western Australia, in April 1990, willprobably give a further boost to global coopera-tion.

National Action in the Third WorldThere is insufficient space to review nationalaction in the Third World in depth but thereare encouraging signs. The activities outlinedabove are beginning to have an effect. In adebate at the World Health Assembly in 1988many developing countries outlined action

they had taken or were contemplating. Thoughactual practice may not always have matchedthese intentions, the debate was good evidenceof a major change in world opinion.The following are a few examples of action

that have been reported in recent years. Alltobacco promotion has been banned in Sin-gapore and Tahiti and this is at least beingdiscussed in government circles in India. Leg-islative action on advertising has also beentaken in Sudan, Ethiopia, Gambia, andGuinea. Advertising on television has nowbeen prohibited in several countries. With themounting evidence of the ill effects of passivesmoking" many countries are limiting smokingin public places; some have made all domesticairline flights non-smoking. China, now theworld's biggest consumer of tobacco, hasbegun to appreciate the imminent health dis-aster'7 and is actively considering legislation.Non-governmental campaigning organisationsare becoming established in many countries.Among others these include India, Bangladesh,Kenya, Tanzania, and Swaziland.

ECONOMIC PROBLEMSSome countries, especially in Africa, haverelied heavily on tobacco growing as a source offoreign exchange. They are accordinglynervous about international or national tobaccocontrol, especially in view of their vast debts,which are in turn affecting health.6" Tobaccogrowing, of course, diverts land from foodproduction.46 The use of wood for tobaccocuring causes deforestation and desertification.Moreover, with the growth of indigenoussmoking, an increasing proportion of the cropoften comes to be consumed locally and ceasesto earn foreign exchange. The Food andAgriculture Organisation (FAO) of the UnitedNations is now prepared to help countries tofind alternative marketable crops; it is ceasingto sponsor tobacco growing projects. AlreadyCongo has converted a large industrial projectfrom tobacco to soya. But so far countries havebeen slow to request this help.

Action by all of usPhysicians have led opinion on this issue.'267They can still make major contributions to thebuild up of opinion in countries not yet facingup to the tobacco threat. They can encouragediscussion and action in many contexts,medical and other.6' What needs to be done isnow well known and can be found in severalpublications.6 8 553 54 58 60 Some countrieshave implemented certain items, legislative orother;50 these actions have often shown an effectin reducing the smoking rates.54 So far nocountry has implemented the full sweep of therecommendations. This could have a far moredramatic effect. And this, worldwide, is whatwe must all endeavour to bring about.

I am grateful to David Simpson, director ofAction on Smoking and Health (ASH) UK, forhelpful criticism of an earlier draft of thisreport.

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169Tobacco and the Third World

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