Elsevier

The Lancet

Volume 380, Issue 9842, 18–24 August 2012, Pages 668-679
The Lancet

Articles
Tobacco use in 3 billion individuals from 16 countries: an analysis of nationally representative cross-sectional household surveys

https://doi.org/10.1016/S0140-6736(12)61085-XGet rights and content

Summary

Background

Despite the high global burden of diseases caused by tobacco, valid and comparable prevalence data for patterns of adult tobacco use and factors influencing use are absent for many low-income and middle-income countries. We assess these patterns through analysis of data from the Global Adult Tobacco Survey (GATS).

Methods

Between Oct 1, 2008, and March 15, 2010, GATS used nationally representative household surveys with comparable methods to obtain relevant information from individuals aged 15 years or older in 14 low-income and middle-income countries (Bangladesh, Brazil, China, Egypt, India, Mexico, Philippines, Poland, Russia, Thailand, Turkey, Ukraine, Uruguay, and Vietnam). We compared weighted point estimates and 95% CIs of tobacco use between these 14 countries and with data from the 2008 UK General Lifestyle Survey and the 2006–07 US Tobacco Use Supplement to the Current Population Survey. All these surveys had cross-sectional study designs.

Findings

In countries participating in GATS, 48·6% (95% CI 47·6–49·6) of men and 11·3% (10·7–12·0) of women were tobacco users. 40·7% of men (ranging from 21·6% in Brazil to 60·2% in Russia) and 5·0% of women (0·5% in Egypt to 24·4% in Poland) in GATS countries smoked a tobacco product. Manufactured cigarettes were favoured by most smokers (82%) overall, but smokeless tobacco and bidis were commonly used in India and Bangladesh. For individuals who had ever smoked daily, women aged 55–64 years at the time of the survey began smoking at an older age than did equivalently aged men in most GATS countries. However, those individuals who had ever smoked daily and were aged 25–34-years when surveyed started to do so at much the same age in both sexes. Quit ratios were very low (<20% overall) in China, India, Russia, Egypt, and Bangladesh.

Interpretation

The first wave of GATS showed high rates of smoking in men, early initiation of smoking in women, and low quit ratios, reinforcing the view that efforts to prevent initiation and promote cessation of tobacco use are needed to reduce associated morbidity and mortality.

Funding

Bloomberg Philanthropies' Initiative to Reduce Tobacco Use, Bill and Melinda Gates Foundation, Brazilian and Indian Governments.

Introduction

Tobacco use has long been a leading contributor to premature death, and causes about 9% of deaths worldwide.1 Presently, the burden of tobacco use is greatest in high-income countries (18% of deaths are attributable to tobacco use), intermediate in middle-income countries (11%), and lowest in low-income countries (4%).1 However, because rates of smoking are increasing in many low-income and middle-income countries (and decreasing in most high-income countries), the proportion of deaths from tobacco use could increase in low-income and middle-income countries as the number of tobacco-attributable deaths increases.1, 2 According to WHO, nearly 6 million people die from tobacco-related causes every year.2 If present patterns of use persist, tobacco use could cause as many as 1 billion premature deaths globally during the 21st century.2

Although most of the tobacco that is consumed throughout the world is in the form of manufactured cigarettes, it is also smoked in other products, such as cigars, cigarillos, pipes, waterpipes, kreteks (clove cigarettes), bidis (tobacco in a tendu or temburni leaf that is tied with a cotton thread), and papirosy (cardboard tube-tipped cigarettes).3 Waterpipes are commonly used in Middle Eastern countries and some Asian countries. Kreteks are the dominant tobacco product consumed in Indonesia and bidis are smoked widely in the Indian subcontinent (Bangladesh, Bhutan, India, Nepal, Pakistan, and Sri Lanka). Papirosy are smoked in Russia. Many types of smokeless tobacco products exist. Various forms of loose-leaf chewed tobacco are commonly consumed in the Indian subcontinent. For example, betel quid is made of tobacco, areca nut, slaked lime, and flavouring agents, all of which are wrapped in a betel leaf. Snuff (finely-chopped tobacco) is used in many countries and in some is branded with the names of leading cigarette varieties.

As for any major cause of disease, monitoring of tobacco use around the world is imperative. Accurate documentation of tobacco use by population-based surveys facilitates understanding of disease patterns, provides an indication of the effectiveness of tobacco-control strategies and how they should be changed, and points to programmatic and research needs.4 The Global Tobacco Surveillance System was created by WHO, the US Centers for Disease Control and Prevention (CDC), and the Canadian Public Health Association5 “to enhance country capacity to design, implement and evaluate tobacco-control interventions, and monitor key articles of the WHO's Framework Convention on Tobacco Control and components of the WHO MPOWER technical package.”6 Such activities are required by WHO's Framework Convention on Tobacco Control,7 which is a broad treaty for global tobacco control. We report indicators of use and cessation from the first wave of the Global Adult Tobacco Survey (GATS), which was recently undertaken in 14 low-income and middle-income countries (Bangladesh, Brazil, China, Egypt, India, Mexico, Philippines, Poland, Russia, Thailand, Turkey, Ukraine, Uruguay, and Vietnam) that collectively contribute to most of the disease burden attributable to tobacco use. For comparison, we include data from nationally representative surveys in the UK and USA, and thus provide nationally representative data on tobacco use in 16 countries with a total population of about 3 billion individuals aged 15 years or older.

Section snippets

Study design and participants

Detailed descriptions of GATS,8, 9 the UK General Lifestyle Survey,10 and the US Tobacco Use Supplement to the Current Population Survey11 (hereafter referred to as the Tobacco Use Supplement) are available elsewhere (appendix p 2). Even though the General Lifestyle Survey did not sample in Northern Ireland, we refer to it as a UK survey for reasons of simplicity.

GATS is a household-based survey, designed to obtain nationally representative data in low-income and middle-income countries for the

Results

Table 1 shows sex-specific and country-specific patterns of tobacco use, and sample sizes are shown in appendix p 6. Prevalence of smoking any tobacco product was generally much higher for men than women in every GATS country (figure, appendix p 7). In men, the prevalence of current smoking ranged from 21·6% (95% CI 20·8–22·4) in Brazil to 60·2% (58·4–62·0) in Russia. In women, current smoking prevalence ranged from 0·5% (0·3–0·8) in Egypt to 24·4% (22·8–26·0) in Poland. In the UK, about the

Discussion

We report data that depict the global epidemic of tobacco use at the start of the 21st century. Collectively, GATS data and surveys from the UK and USA document the enormity of the epidemic and reinforce the need for effective tobacco control (panel 2). Of about 3 billion individuals aged 15 years or older living in the UK, USA, and 14 GATS countries, we estimated that 852 million were tobacco users, including 301 million in China and 275 million in India. Several general patterns can be

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