Epidemiology of smoking in Ukraine, 2000

Tobacco Use Worldwide: Legislative Efforts to Curb Consumption

Tobacco smoking is recognized as a major preventable cause of disease worldwide and is linked to 6 million deaths annually, 30% of which are due to cancer. The negative health consequences of smoking currently represent one of the greatest global public health challenges. Additionally, secondhand smoke, which was declared carcinogenic by the International Agency for Research on Cancer in 2004, is a major source of morbidity and premature death in nonsmokers, particularly children. Negative health effects associated with exposure to secondhand smoke have been well documented and include lung cancer, cardiovascular disease, asthma, and other respiratory diseases. International and national policies to implement cost-effective strategies to curtail smoking will have a significant impact on population health and will protect nonsmokers. Effective interventions, such as smoking bans, tobacco price increases, easy access to tobacco cessation treatments, and anti-tobacco media campaigns, should continue. Reducing tobacco use would be a major step towards the goal of decreasing health disparities by 2030, as 80% of the projected tobacco-related deaths will occur in low and middle-income countries.

Tobacco Use Worldwide: Legislative Efforts to Curb Consumption

Tobacco smoking is recognized as a major preventable cause of disease worldwide and is linked to 6 million deaths annually, 30% of which are due to cancer. The negative health consequences of smoking currently represent one of the greatest public health challenges. Secondhand smoke, declared carcinogenic by the International Agency for Research on Cancer in 2004, is also a major source of morbidity and premature death in nonsmokers, particularly children. Negative health effects associated with exposure to secondhand smoke have been well documented and include lung cancer, cardiovascular disease, asthma, and other respiratory diseases. International and national policies to implement cost-effective strategies to curtail smoking will have a significant impact on population health and will protect nonsmokers. Effective interventions, such as a combination of smoke-free laws, tobacco price increases, easy access to tobacco cessation treatments, and anti-tobacco media campaigns, should continue. Reducing tobacco use would be a major step towards the goal of decreasing health disparities by 2030 as 80% of the projected tobacco-related deaths will occur in low- and middle-income countries.

Tobacco Use Worldwide: Legislative Efforts to Curb Consumption

Tobacco smoking is recognized as a major preventable cause of disease worldwide and is linked to 6 million deaths annually, 30% of which are due to cancer. The negative health consequences of smoking currently represent one of the greatest public health challenges. Secondhand smoke, declared carcinogenic by the International Agency for Research on Cancer in 2004, is also a major source of morbidity and premature death in nonsmokers, particularly children. Negative health effects associated with exposure to secondhand smoke have been well documented and include lung cancer, cardiovascular disease, asthma, and other respiratory diseases. International and national policies to implement cost-effective strategies to curtail smoking will have a significant impact on population health and will protect nonsmokers. Effective interventions, such as a combination of smoke-free laws, tobacco price increases, easy access to tobacco cessation treatments, and anti-tobacco media campaigns, should continue. Reducing tobacco use would be a major step towards the goal of decreasing health disparities by 2030 as 80% of the projected tobacco-related deaths will occur in low- and middle-income countries.

Prevalence and factors associated with smoking among adults in Malaysia: Findings from the National Health and Morbidity Survey (NHMS) 2015

INTRODUCTION

The continuous monitoring of smoking prevalence and its associated factors is an integral part of anti-smoking programmes and valuable for the evaluation of the effectiveness of anti-smoking measures and policies. This study aimed at determining prevalence of smoking and identifying socio-demographic factors associated with smoking among adults in Malaysia aged 15 years and over.

METHODS

This is a cross-sectional study with a representative sample of 21 445 adults in Malaysia, aged 15 years and over, selected via a stratified, two-stage proportionate-to-size sampling method. Data were obtained from face-to-face interviews by trained research assistants, using a standard validated questionnaire. Multivariable logistic regression was performed to determine socio-demographic factors associated with smoking among Malaysians.

RESULTS

The overall prevalence of smoking was 22.8% (95% CI: 21.9-23.8%), with males having a significantly higher prevalence compared to females (43.0%, 95% CI: 41.1-44.6 vs 1.4%, 95% CI: 1.1-1.7). The highest smoking prevalence was observed among other ethnicities (35.7%), those aged 25-44 years (59.3%), and low educational attainment (25.2%). Males, those with lower educational attainment and Malays were significantly associated with smoking.

CONCLUSIONS

The prevalence of smoking among Malaysians, aged 15 years and over, remains high despite the implementation of several anti-smoking measures over the past decades. Specially tailored anti-smoking policies or measures, particularly targeting males, the Malays, younger adults and those with lower educational attainment, are greatly warranted to reduce the prevalence of smoking in Malaysia.

Social inequalities in self-rated health in Ukraine in 2007: the role of psychosocial, material and behavioural factors

Background

Despite Ukraine's large population, few studies have examined social inequalities in health. This study describes Ukrainian educational inequalities in self-rated health and assesses how far psychosocial, material and behavioural factors account for the education gradient in health.

Methods

Data were analyzed from the 2007 wave of the Ukrainian Longitudinal Monitoring Survey. Education was categorized as: lower secondary or less, upper secondary and tertiary. In logistic regressions of 5451 complete cases, stratified by gender, declaring less than average health was regressed on education, before and after adjusting for psychosocial, material and behavioural factors.

Results

In analyses adjusted for socio-demographic characteristics, compared with those educated up to lower secondary level, tertiary education was associated with lower risk of less than average health for both men and women. Including material factors (income quintiles, housing assets, labour market status) reduced the association between education and health by 55-64% in men and 35-47% in women. Inclusion of health behaviours (physical activity, smoking, alcohol consumption and body mass index) reduced the associations by 27-30% in men and 19-27% in women; in most cases including psychosocial factors (marital status, living alone, trust in family and friends) did not reduce the size of the associations. Including all potential explanatory factors reduced the associations by 68-84% in men and 43-60% in women.

Conclusions

The education gradient in self-rated health in Ukraine was partly accounted for by material and behavioural factors. In addition to health behaviours, policymakers should consider upstream determinants of health inequalities, such as joblessness and poverty.

Burden of serious fungal infections in Ukraine

Ukraine has high rates of TB, AIDS and cancer. We estimated the burden of fungal disease from epidemiology papers and specific populations at risk and fungal infection frequencies. HIV/AIDS cases and deaths (2012) and tuberculosis statistics were obtained from the State Service of Ukraine, while chronic obstructive pulmonary disease (COPD) cases were from M. Miravitlles et al., Thorax 64, 863-868 (2009). Annual estimates are 893,579 Ukrainian women get recurrent vaginal thrush (≥4× per year), 50,847 cases of oral candidiasis and 13,727 cases of oesophageal candidiasis in HIV, and 101 (1%) of 10,085 new AIDS cases develop cryptococcal meningitis, 6152 cases of Pneumocystis pneumonia (13.5 cases per 100,000). Of the 29,265 cases of active respiratory TB in 2012, it is estimated that 2881 new cases of chronic pulmonary aspergillosis (CPA) occurred and that the 5-year period prevalence is 7724 cases with a total CPA burden of 10,054 cases. Assuming adult asthma prevalence is ~2.9%, 28,447 patients with allergic bronchopulmonary aspergillosis (ABPA) are likely and 37,491 with severe asthma with fungal sensitisation. We estimate 2278 cases and 376 postsurgical intra-abdominal Candida infections. Invasive aspergillosis in immunocompromised patients is estimated at 303 patients annually; 930 cases in COPD patients. Ninety cases of mucormycosis (2 per 1,000,000) are estimated. In total, ~1,000,000 (2.2%) people in Ukraine develop serious fungal infections annually.

Prevalence of smoking and its associated factors with smoking among elderly smokers in Malaysia: findings from a nationwide population-based study

BACKGROUND

The determination of smoking prevalence and its associated factors among the elderly could provide evidence-based findings to guide the planning and implementation of policy in order to will help in reducing the morbidity and mortality of smoking-related diseases, thus increase their quality of life. This paper describes the rate of smoking and identifies the factor(s) associated with smoking among the elderly in Malaysia.

METHODS

A representative sample of 2674 respondents was obtained via a two-stage sampling method in proportion to population size. Face-to-face interviews were conducted using a set of standardized validated questionnaire. Data was weighted by taking into consideration the complex sampling design and non-response rate prior to data analysis. Univariable and multivariable logistic regression were used to determine the factor/s associated with smoking.

RESULTS

The prevalence of non-smokers, ex-smokers and current smokers among Malaysians aged 60 years and above were 36.3 % (95 % CI = 32.7-39.8), 24.4 % (95 % CI = 21.2-27.5) and 11.9 % (95 % CI = 9.5-14.3), respectively. Current smokers were significantly more prevalent in men (28.1 %) than in women (2.9 %), but the prevalence declined with advancing age, higher educational attainment, and among respondents with known diabetes, hypertension and hypercholesterolemia. Multivariable analysis revealed that males (aOR, 18.6, 95 % CI 10.9-31.9) and other Bumiputras (aOR 2.58, 95 % CI 1.29-5.15) were more likely to smoke. in addition, elderly with lower educational attainment (aOR, 1.70, 95 % CI 1.24-7.41) and those without/unknown hypertension also reported higher likelihood to be current smokers (aOR 1.98, 95 % CI 1.35-2.83). However, there were no significant associations between respondents with no/unknown diabetes or hypercholesterolemia with smoking.

CONCLUSIONS

In short, smoking is common among elderly men in Malaysia. Therefore, intervention programs should integrate the present findings to reduce the smoking rate and increase the smoking cessation rate among the elderly in Malaysia and subsequently to reduce the burden of smoking-related disease.

A Systematic Review of Tobacco Smoking Prevalence and Description of Tobacco Control Strategies in Sub-Saharan African Countries; 2007 to 2014

Objective

To systematically review current smoking prevalence among adults in sub-Saharan Africa from 2007 to May 2014 and to describe the context of tobacco control strategies in these countries.

Data Sources

Five databases, Medline, Embase, Africa-wide Information, Cinahl Plus, and Global Health were searched using a systematic search strategy. There were no language restrictions.

Study Selection

26 included studies measured current smoking prevalence in nationally representative adult populations in sub-Saharan African countries.

Data Extraction

Study details were independently extracted using a standard datasheet. Data on tobacco control policies, taxation and trends in prices were obtained from the Implementation Database of the WHO FCTC website.

Results

Studies represented 13 countries. Current smoking prevalence varied widely ranging from 1.8% in Zambia to 25.8% in Sierra Leone. The prevalence of smoking was consistently lower in women compared to men with the widest gender difference observed in Malawi (men 25.9%, women 2.9%). Rwanda had the highest prevalence of women smokers (12.6%) and Ghana had the lowest (0.2%). Rural, urban patterns were inconsistent. Most countries have implemented demand-reduction measures including bans on advertising, and taxation rates but to different extents.

Conclusion

Smoking prevalence varied widely across sub-Saharan Africa, even between similar country regions, but was always higher in men. High smoking rates were observed among countries in the eastern and southern regions of Africa, mainly among men in Ethiopia, Malawi, Rwanda, and Zambia and women in Rwanda and rural Zambia. Effective action to reduce smoking across sub-Saharan Africa, particularly targeting population groups at increased risk remains a pressing public health priority.

The economic burden of chronic disease care faced by households in Ukraine: a cross-sectional matching study of angina patients

Introduction

Non-communicable diseases (NCDs) are the leading cause of death and disability worldwide, and their prevalence in lower- and middle-income countries (LMIC) is on the rise. The burden of chronic health expenditure born by patient households in these countries may be very high, particularly where out-of-pocket payments for health care are common. One such country where out-of-pocket payments are especially high is Ukraine. The financial impact of NCDs on households in this country has not been researched.

Methods

We set out to explore the burden of NCD care in Ukraine with a study of angina patients. Using data from the Ukraine World Health Survey of 2003 we employed the novel Coarsened Exact Matching approach to estimate the difference in out-of-pocket payment (OPP) for health care between households with a stable angina pectoris (a chronic form of IHD) patient and those without. The likelihood of engaging in catastrophic spending and using various distress financing mechanisms (e.g. sale of assets, borrowing) among angina households compared with non-angina households was also explored.

Results

Among angina patient households (n = 203), OPP occupied an average of 32% of household effective income. After matching, angina households experienced significantly higher monthly per capita OPP for health care (B = $2.84) and medicines (B = $2.94), but were not at significantly higher odds of engaging in catastrophic spending. Odds of engaging in ‘sale of assets’ (OR = 2.71) and ‘borrowing’ (OR = 1.68) to finance OPP were significantly higher among angina households.

Conclusions

The cost of chronic care in Ukraine places a burden on individual patient households. Households of angina patients are more likely to engage in distress financing to cover the cost of treatment, and a high proportion of patients do not acquire prescribed medicines because they cannot afford them. This warrants further research on the burden of NCD care in other LMIC, especially where OPP for health care is common. Health policies aimed at reducing OPP for health care, and especially medicines, would lessen the high health and financial burden of chronic care. Further research is also needed on the long-term impact of borrowing or sale of assets to finance OPP on patient households.

A country divided? Regional variation in mortality in Ukraine

OBJECTIVES

We set out to identify the contribution of various causes of death to regional differences in life expectancy in Ukraine.

METHODS

Mortality data by oblast (province) were obtained from the State Statistical Committee of Ukraine. The contribution of various causes of death to differences in life expectancy between East, West and South Ukraine was estimated using decomposition.

RESULTS

In 2008, life expectancy for men in South (61.8 years) and East Ukraine (61.2 years) was lower than for men in West Ukraine (64.0 years). A similar pattern was observed among women. This was mostly due to deaths from infectious disease and external causes among young adults, and cardio- and cerebro-vascular deaths among older adults. Deaths from TB among young adults contribute most to differences in life expectancy.

CONCLUSIONS

Deaths due to infectious disease, especially TB, play an important role in the gap in life expectancy between regions in Ukraine. These deaths are entirely preventable--further research is needed to identify what has 'protected' individuals in Western Ukraine from the burden of deaths experienced by their Southern and Eastern counterparts.

Epidemiology of smoking among Malaysian adult males: prevalence and associated factors

BACKGROUND

Three National Health and Morbidity Surveys (NHMSs) had been conducted in Malaysia in 10-year intervals from 1986-2006. Based on the latest NHMS survey in 2006, we describe the prevalence of smoking and identify the social and demographic factors associated with smoking among adult males in Malaysia.

METHODS

A cross-sectional study among 15,639 Malaysian adult males aged 18 years and above was conducted using proportional to size stratified sampling method. The socio-demographic variables examined were level of education, occupation, marital status, residential area, age group and monthly household income.

RESULTS

The prevalence of smoking among adult males in Malaysia was 46.5% (95% CI: 45.5-47.4%), which was 3% lower than a decade ago. Mean age of smoking initiation was 18.3 years, and mean number of cigarettes smoked daily was 11.3. Prevalence of smoking was highest among the Malays (55.9%) and those aged 21-30 years (59.3%). Smoking was significantly associated with level of education (no education OR 2.09 95% CI (1.67-2.60), primary school OR 1.95, 95% CI (1.65-2.30), secondary school OR 1.88, 95% CI (1.63-2.11), with tertiary education as the reference group). Marital status (divorce OR 1.67, 95% CI (1.22-2.28), with married as the reference group), ethnicity (Malay, OR 2.29, 95% CI ( 1.98-2.66; Chinese OR 1.23 95% CI (1.05-1.91), Other Bumis OR 1.75, 95% CI (1.46-2.10, others OR 1.48 95% CI (1.15-1.91), with Indian as the reference group), age group (18-20 years OR 2.36, 95% CI (1.90-2.94); 20-29 years OR 3.31 , 95% CI 2.82-3.89; 31-40 years OR 2.85 , 95% CI ( 2.47-3.28); 41-50 years OR 1.93, 95% CI (1.69-2.20) ; 51-60 years OR 1.32, 95% CI (1.15-1.51), with 60 year-old and above as the reference group) and residential area (rural OR 1.12 , 95% CI ( 1.03-1.22)) urban as reference.

CONCLUSION

The prevalence of smoking among Malaysian males remained high in spite of several population interventions over the past decade. Tobacco will likely remain a primary cause of premature mortality and morbidity in Malaysia. Continuous and more comprehensive anti-smoking policy measures are needed in order to further prevent the increasing prevalence of smoking among Malaysian men, particularly those who are younger, of Malay ethnicity, less educated, reside in rural residential area and with lower socio-economic status.

[Factors associated with smoking in the elderly: a health survey in São Paulo (ISA-SP)]

This article reports on smoking prevalence and associated factors in the elderly, based on a population-based cross-sectional study with multi-stage sampling including 1,954 individuals 60 years or older living in four areas of São Paulo State, Brazil. Overall smoking prevalence was 12.2%, and higher rates were associated with male gender, age 60-69 years, not belonging to an Evangelical church, lower income, low body weight, lack of leisure-time physical activity, depression/anxiety, and hypertension. There was a high prevalence of smokers among individuals with a history of stroke, cancer, and chronic obstructive pulmonary disease. The results point to the need for effective interventions in healthcare services to promote smoking cessation among the elderly, since many are unable to stop on their own, even when they have tobacco-related illnesses. Special attention should be paid to individuals that depend on the National Health System, since smoking prevalence is higher in underprivileged socioeconomic groups.

Changes in smoking prevalence in 8 countries of the former Soviet Union between 2001 and 2010

OBJECTIVES

We sought to present new data on smoking prevalence in 8 countries, analyze prevalence changes between 2001 and 2010, and examine trend variance by age, location, education level, and household economic status.

METHODS

We conducted cross-sectional household surveys in 2010 in Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, and Ukraine. We compared smoking prevalence with a related 2001 study for the different countries and population subgroups, and also calculated the adjusted prevalence rate ratios of smoking.

RESULTS

All-age 2010 smoking prevalence among men ranged from 39% (Moldova) to 59% (Armenia), and among women from 2% (Armenia) to 16% (Russia). There was a significantly lower smoking prevalence among men in 2010 compared with 2001 in Belarus, Kazakhstan, Kyrgyzstan, and Russia, but not for women in any country. For all countries combined, there was a significantly lower smoking prevalence in 2010 than in 2001 for men aged 18 to 39 years and men with a good or average economic situation.

CONCLUSIONS

Smoking prevalence appears to have stabilized and may be declining in younger groups, but remains extremely high among men, especially those in lower socioeconomic groups.

A review of the impacts of tobacco industry privatisation: Implications for policy

State-owned tobacco companies, which still account for 40% of global cigarette production, face continued pressure from, among others, the International Monetary Fund (IMF), to be privatised. This review of available literature on tobacco industry privatisation suggests that any economic benefits of privatisation may be lower than supposed, because private owners avoid competitive tenders (thus underpaying for assets), negotiate lengthy tax holidays and are complicit in the smuggling of cigarettes to avoid import and excise duties. It outlines how privatisation leads to increased marketing, more effective distribution and lower prices, creating additional demand for cigarettes among new and existing smokers, leading to increased cigarette consumption, higher smoking prevalence and lower age of smoking initiation. Privatisation also weakens tobacco control because private owners, in their drive for profits, lobby aggressively against effective policies and ignore or overturn existing policies. This evidence suggests that further tobacco industry privatisation is likely to increase smoking and that instead of transferring assets from state to private ownership, alternative models of supply should be explored.

Tobacco use among the elderly: a systematic review and meta-analysis

The aim of this study was to combine the results of identified surveys on the prevalence of tobacco use in old age to estimate world prevalence of tobacco use and possible factors related to such behavior among the elderly. The literature search included electronic databases such as MEDLINE, LILACS, and Biological Abstracts, hand-searching of specialist journals and cited reference searches. The combined global prevalence was estimated using the random effects model. The total number of elderly subjects included in all surveys was 140,058, with data available from all the continents. Overall prevalence of tobacco use was 13% in both genders (22% male and 8% female). The prevalence rates were heterogeneous among surveys and were associated with smoking definition, questionnaire application, and country economic status. Few epidemiological studies assessed tobacco use among the elderly. A higher prevalence rate of tobacco use in males who live in higher income countries could be found, although additional evidence regarding elderly samples is still required.

A prevalence study of current tobacco smoking in later life community and its association with sociodemographic factors, physical health and mental health status

OBJECTIVE

Evaluate the frequency of current smoking in elderly people living in urban areas of Rio Grande do Sul, Brazil.

METHODS

Cross-sectional design. A representative sample of 6,961 elderly, randomly selected subjects, living in a community, was examined to estimate the frequency of current tobacco smoking. Tobacco use was measured by means of a household questionnaire administered by trained interviewers that inquired about current tobacco use, sociodemographic characteristics, self-rated physical and health status. Mental health was evaluated using the Short Psychiatric Evaluation Schedule (SPES).

RESULTS

The prevalence of tobacco use was 28.9% among men, 13.6% among women and 18.8% for both sexes. Male gender (OR = 3.25), low income (OR = 1.52), years of schooling (illiterate) (OR = 1.35), non-Protestant religion (OR = 2.17) and absence of physical exercise (OR = 1.21) presented positive and independent association with tobacco use. Presence of pulmonary disease (OR = 1.93) and mental distress (OR = 1.32) and absence of cardiac disease (OR = 1.51), high blood pressure (OR = 1.51) and diabetes (OR = 1.50) were independently associated with an increased chance of current tobacco use. Increasing age (OR = 0.93) and marital status (married) (OR = 0.66) presented independent and negative association with smoking.

CONCLUSION

Factors associated with an increased chance of tobacco smoking were: being men, illiterate, with lower income, presence of respiratory and mental disease, and absence of cardiac disease, high blood pressure and diabetes. Factors associated with a decreased risk of tobacco smoking were: aging, exercise, Protestant religion and marriage.

Changes in smoking prevalence in Ukraine in 2001-5

OBJECTIVES

To analyse trends in smoking prevalence in Ukraine from three surveys conducted in 2001-5, and to explore correlates of observed changes, in order to estimate the stage of tobacco epidemic in Ukraine.

DESIGN

Repeated national interview surveys in Ukraine in 2001, 2002 and 2005.

MAIN OUTCOME MEASURE

Prevalence of current smoking among the population aged > or = 15 years.

RESULTS

The age-standardised prevalence of current smoking in Ukrainian men was 54.8% in 2001 and 66.8% in 2005. Among Ukrainian women, prevalence increased from 11.5% in 2001 to 20.0% in 2005. ORs for yearly increase in prevalence were estimated as 1.164 (95% CI 1.111 to 1.220) for men and 1.187 (1.124 to 1.253) for women, which implies that, on average, 3-4% of men and 1.5-2% of women living in Ukraine join the smoking population each year.

CONCLUSIONS

In Ukraine, smoking prevalence is increasing in most population groups. Among men, the medium deprivation group with secondary education has the highest smoking prevalence. Among women, while the most educated, young and those living in larger cities are the leading group for tobacco use, other groups are also increasing their tobacco use. Tobacco promotion efforts appear to have been significantly more effective in Ukraine than smoking control efforts. The decrease in real cigarette prices in Ukraine in 2001-5 could be the main factor explaining the recent growth in smoking prevalence.

Trends in the prevalence of smoking in Russia during the transition to a market economy

BACKGROUND

Changes in smoking, particularly an increase in women, were predicted to follow the aggressive campaigns of multinational tobacco companies in transitional Russia. However, such changes have not yet been demonstrated unequivocally.

OBJECTIVE

To examine smoking trends by gender, education and area of residence.

METHODS

Data from 10 rounds of the Russia Longitudinal Monitoring Survey (1992-2003), consisting of more than 3000 men and 4000 women in each round, were used. The mean reported ages of first smoking in current smokers were compared between 10-year birth cohorts.

RESULTS

Between 1992 and 2003, smoking prevalence doubled among women from 6.9% (95% CI 6.3% to 7.6%) to 14.8% (13.9% to 15.7%) and increased among men from 57.4% (95% CI 56.0% to 58.8%) to 62.6% (61.1% to 64.1%). In both sexes, the rise was significantly greater in the least educated, markedly so in women (a doubling vs a 1.5-fold rise in the most educated). Although prevalence of smoking among women was considerably higher in Moscow and St Petersburg than in rural areas, the dramatic threefold increase in prevalence in rural women was significantly greater than in the main cities (36%, p<0.001). The mean age of first smoking was significantly lower in women born after 1960, but in men it was stable between cohorts.

CONCLUSIONS

For the first time, it has been shown unequivocally that smoking among women increased markedly during the transition to a market economy in Russia. The already high prevalence of smoking among men has continued to rise. These changes are likely to reflect the activity of the tobacco industry and provide further evidence of the harms of privatisation. Effective tobacco control policies are urgently needed.

Smoking initiation and nicotine dependence symptoms in Ukraine: findings from the Ukraine World Mental Health survey

OBJECTIVES

Cigarette smoking is a major cause of morbidity and mortality in former Soviet countries. This study examined the personal, familial and psychiatric risk factors for smoking initiation and development of nicotine dependence symptoms in Ukraine.

STUDY DESIGN

Cross-sectional survey.

METHODS

Smoking history and dependence symptoms were ascertained from N=1711 adults in Ukraine as part of a national mental health survey conducted in 2002. Separate analyses were conducted for men and women.

RESULTS

The prevalence of lifetime regular smoking was 80.5% in men and 18.7% in women, with median ages at initiation among smokers of 17 and 18, respectively. Furthermore, 61.2% of men and 11.9% of women were current smokers; among the subgroup of lifetime smokers, 75.9% of men and 63.1% of women currently smoked. The youngest female cohort (born 1965-1984) was 26 times more likely to start smoking than the oldest. Smoking initiation was also linked to childhood externalizing behaviors and antecedent use of alcohol in both genders, as well as marital status and personal alcohol abuse in men, and childhood urbanicity and birth cohort in women. Dependence symptoms developed in 61.7% of male and 47.1% of female smokers. The rate increased sharply in the first four years after smoking initiation. Dependence symptoms were related to birth cohort and alcohol abuse in both genders, as well as growing up in a suburb or town and childhood externalizing behaviors in men, and parental antisocial behavior in women.

CONCLUSIONS

Increased smoking in young women heralds a rising epidemic in Ukraine and underscores the need for primary prevention programs, especially in urban areas. Our findings support the importance of childhood and alcohol-related risk factors, especially in women, while pre-existing depression and anxiety disorders were only weakly associated with starting to smoke or developing dependence symptoms.

Influence of household demographic and socio-economic factors on household expenditure on tobacco in six New Independent States

Background

To identify demographic and socio-economic factors that are associated with household expenditure on tobacco in Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Russian Federation, and Tajikistan.

Methods

Secondary analysis of the data available through the World Bank Living Standards Monitoring Survey conducted in aforementioned countries in 1995–2000. The role of different variables (e.g. mean age of household members, household area of residence, household size, share of adult males, share of members with high education) in determining household expenditure on tobacco (defined as tobacco expenditure share out of total monthly HH consumption) was assessed by using multiple regression analysis.

Results

Significant differences were found between mean expenditure on tobacco between rich and poor – in absolute terms the rich spend significantly more compared with the poor. Poor households devote significantly higher shares of their monthly HH consumption for tobacco products. Shares of adult males were significantly associated with the share of household consumption devoted for tobacco. There was a significant negative association between shares of persons with tertiary education within the HH and shares of monthly household consumption devoted for tobacco products. The correlation between household expenditures on tobacco and alcohol was found to be positive, rather weak, but statistically significant.

Conclusion

Given the high levels of poverty and high rates of smoking in the New Independent States, these findings have important policy implications. They indicate that the impact and opportunity costs of smoking on household finances are more significant for the poor than for the rich. Any reductions in smoking prevalence within poor households could have a positive economic impact.

Social determinants of ever initiating smoking differ from those of quitting: a cross-sectional study in Estonia

BACKGROUND

To study the association of socioeconomic and demographic indicators with ever initiating regular smoking and quitting smoking among ever regular smokers in Estonia in order to identify target groups for equity-oriented tobacco control policies.

METHODS

Data for 4277 individuals in the 25-64 age group come from three cross-sectional studies conducted in 2000, 2002 and 2004. Age-standardized prevalence rates and odds ratios with 95% confidence intervals were calculated.

RESULTS

High rates of ever initiation were observed for lower educated men and women after controlling for other socioeconomic indicators. This association was not observed for women above age 50. Independent, although weaker associations were found among men who were unemployed or with a low occupational status. Low cessation rates were observed among men who were unemployed, who had a lower occupational position or who had a low income. These associations remained after controlling for other socioeconomic variables. The effect of income became stronger in the older age groups among men. Rates of ever initiation and cessation also varied strongly in relationship to some demographic variables. The highest initiation rates were found among divorced women and among women living in the capital city. The lowest cessation rates were found among divorced women, and among Russian men.

CONCLUSIONS

While educational level was the strongest predictor of ever initiating regular smoking, smoking cessation was related more directly to aspects of social disadvantage originating in adult life. To be effective, tobacco control interventions should not only target lower educated, but also those in material disadvantage.

Changes in smoking prevalence in Russia, 1996-2004

OBJECTIVES

In Russia, smoking prevalence has historically been high in men and relatively low in women. Female smoking prevalence is predicted to rise but assessment of changes has been limited by the lack of comparable data. Changes in the prevalence of smoking in Russia between 1996 and 2004, and whether theses changes differed by sociodemographic groups, were investigated.

DESIGN

Repeated national interview surveys in 1996 (731 men and 868 women) and 2004 (727 men and 864 women) aged 18 years or more.

MAIN OUTCOME MEASURE

Prevalence of current smoking.

RESULTS

The age standardised prevalence of smoking in 1996 and 2004 was 61% and 63%, respectively in men and 15% and 16%, respectively in women (both p values > 0.4). In men, the prevalence of smoking seemed to decline in those with university education (from 51% to 40%, p = 0.085). Among women, smoking appeared to increase in those with university education (from 10% to 17%, p = 0.071) and low levels of self-reported material deprivation (from 11% to 18%, p = 0.053). There was a pronounced increase in prevalence among women living in villages (from 8% to 14%, p = 0.049); the strong urban/rural gradient seen in 1996 became considerably weaker by 2004.

CONCLUSIONS

Overall smoking prevalence in both men and women in Russia remained stable between 1996 and 2004 but, given the sample size, a moderate increase in female smoking cannot be ruled out. In men, smoking increased among the least educated and declined in the most educated. In women the opposite appeared to occur, in addition to an increase in smoking in rural areas. More long term monitoring of smoking patterns in Russia, especially among women, using sufficiently large surveys, is required.

Health and nutrition in Eastern Europe and the former Soviet Union during the decade of transition: a review of the literature

The collapse of the Soviet Union was the most important historical event at the close of the 20th century. The jarring nature of this transition has resulted in large fluctuations in household resources and increased uncertainty in all facets of life for the individuals concerned. Much academic research and popular writing has explored the socioeconomic and political ramifications of bringing these countries into mainstream capitalism. This paper provides a review of the literature examining health outcomes in Eastern Europe and the former Soviet Union during the transition period. The research, which has studied the human face of transition, spans multiple disciplines and it is thus currently difficult for interested researchers to obtain an overview of the basic facts, as well as, the more detailed nuances, concerning developments. This paper highlights what we currently know about health outcomes in transition countries and what we do not know, and suggests future areas of research which may help fill important gaps in our knowledge.

Epidemiology of heavy alcohol use in Ukraine: findings from the world mental health survey

AIMS

To describe the epidemiology of heavy alcohol use in Ukraine, using data from the world mental health (WMH) survey in Ukraine.

METHODS

The WMH composite international diagnostic interview was administered in 2002 to a national probability sample of Ukrainian adults (n=4725). An algorithm for classifying heavy use in the past year was developed from self-reports about the quantity and frequency of drinking, and its convergent validity was demonstrated. Prevalence rates and socio-demographic risk factors were examined separately for men and women.

RESULTS

The 12-month rates of heavy alcohol use were 38.7% in men and 8.5% in women (22.0% overall). Among heavy alcohol users, 92% of men and 52% of women consumed at least 80 g of ethanol in a typical drinking day on a monthly basis in the year before the interview. The most significant risk factors in men and women were age (26-54 years for men; 18-25 years for women), living in the Southeast region, being in the labour force whether employed or unemployed, and for men, low education and being the father of a young child. A highly significant linear relationship of number of risk factors with heavy alcohol use was found for both sexes.

CONCLUSIONS

The rates for men were similar to those reported in a Russian national survey with the exception of Southeast Ukraine where the rate was >10% higher. The highest rates were among men who were middle-aged, fathers and unemployed. Future prospective studies are needed to assess the impact of heavy alcohol use on Ukrainian health, mental health and occupational and social functioning.

Pushing up smoking incidence: plans for a privatised tobacco industry in Moldova

Moldova, one of the former Soviet republics and Europe's poorest country, has so far resisted pressure to privatise its tobacco industry. This paper examines the policies pursued by the transnational tobacco companies in Moldova in order to inform the ongoing debate about tobacco industry privatisation. We analysed relevant internal industry documents made public through litigation. The documents suggest that although a competitive tender for the state owned monopoly was later announced, British American Tobacco (BAT) and the German manufacturer Reemtsma each initially sought to secure a closed deal, with BAT accusing Reemtsma of underhand tactics. Imperial Tobacco, which now owns Reemstma, was unable to comment on these allegations as it only acquired Reemstma after the events in question. BAT sought to acquire a monopoly position, bolstered by excise rules developed by the company that would uniquely favour its products. Despite hoping to establish a monopoly, it planned intensive marketing, as if in a competitive market, aiming to target young urban dwellers, particularly opinion leaders. In so doing it predicted that smoking uptake would increase, especially among women. The documents also suggest that BAT was aware of the sensitive nature of its plans to cull the processing workforce and aimed to present "sanitised" information on future employment levels to the Moldovans. The potential for tobacco industry privatisation to undermine tobacco control and promote cigarette consumption is highlighted and is consistent with economic theory. Countries planning tobacco industry privatisation should ensure a transparent and competitive privatisation process, seek to prevent the predicted increase in consumption by implementing effective tobacco control policies and consider the impacts on employment. Multilateral financial organisations promoting tobacco industry privatisation could ensure their loan conditions protect public health by making the implementation of tobacco control policies a pre-requisite for privatisation.

Tobacco and transition: an overview of industry investments, impact and influence in the former Soviet Union

OBJECTIVES

To quantify the contribution the tobacco industry has made to foreign direct investment (FDI) in the former Soviet Union (FSU) as an indicator of its political and economic leverage; to explore the impact this has had on production capacity and tobacco control in the region.

DESIGN

Data on industry investment and its impact on cigarette production capacity were collated from industry journals, reports, and websites. Data on total FDI were obtained from the European Bank of Reconstruction and Development.

RESULTS

By the end of 2000, transnational tobacco companies (TTCs) had invested over 2.7 billion US dollars in 10 countries of the FSU. Tobacco money as a proportion of FDI varies from 1% to over 30% in Uzbekistan. Cigarette production capacity in the factories receiving investments tripled from 146 to 416 billion cigarettes per annum and the TTCs' market share has increased from nothing to between 50-100% in the markets in which they invested. Findings suggest that the effectiveness of national tobacco control measures corresponds broadly to the nature of the political and economic transition in each country and the size of industry investment, which is determined in part by the political context. Thus more effective measures tend to be seen in democratic states with smaller or no industry investments while the least effective measures are seen in highly centralised, one party states with high levels of industry investment or those with limited governmental capacity.

CONCLUSIONS

The entry of the TTCs at a time of major political and economic change left the FSU particularly vulnerable to industry influence. This influence was enhanced by the industry's significant contribution to FDI, their ability to take over existing state monopolies in all but the largest countries, and the lack of democratic opposition.

Moving East: how the transnational tobacco industry gained entry to the emerging markets of the former Soviet Union-part I: establishing cigarette imports

OBJECTIVES

To identify British American Tobacco's (BAT) reasons for targeting the former Soviet Union following its collapse in 1991 and the initial strategies BAT used to enter the region.

DESIGN

Analysis of tobacco industry documents held at the Guildford BAT archive.

RESULTS

Desire to expand to new markets was based in part on the decline in old markets. The large population, proximity to China, scope to expand sales to women and, in Central Asia, a young population with high growth rates made the former Soviet Union particularly attractive. High consumption rates and unfilled demand caused by previous shortages offered potential for rapid returns on investment. A series of steps were taken to penetrate the markets with the initial focus on establishing imports. The documents suggest that BAT encouraged the use of aid money and barter trade to fund imports and directed the smuggling of cigarettes which graduated from an opportunistic strategy to a highly organised operation. In establishing a market presence, promotion of BAT's brands and corporate image were paramount, and used synonymously to promote both the cigarettes and the company. The tobacco industry targeted young people and women. It used the allure of western products to promote its brands and brand stretching and corporate imagery to pre-empt future marketing restrictions.

CONCLUSIONS

BAT used the chaotic conditions in the immediate post-transition period in the former Soviet Union to exploit legislative loopholes and ensure illegal cigarette imports. Governments of countries targeted by the tobacco industry need to be aware of industry tactics and develop adequate tobacco control policies in order to prevent the exploitation of vulnerable populations. Marketing restrictions that focus on advertising without restricting the use of brand or company promotions will have a limited impact.

Exploring the impact of foreign direct investment on tobacco consumption in the former Soviet Union

BACKGROUND

Tobacco is the single largest cause of morbidity and mortality in the developed world; in the former socialist bloc tobacco kills twice as many men as in the west. Although evidence shows that liberalisation of the cigarette trade through the elimination of import barriers leads to significant increases in consumption, far less is known about the impact of foreign direct investment on cigarette consumption. This paper seeks to explore the impact that the substantial transnational tobacco company investments have had on patterns of tobacco trade and consumption in the former Soviet Union.

DESIGN

Routine data were used to explore trends in cigarette trade and consumption in the 15 countries of the former Soviet Union from the 1960s to the present day. Comparisons were made between trends in countries that have received substantial investment from the tobacco transnationals and countries that have not.

RESULTS

Between 1991 and 2000 cigarette production increased by 96% in countries receiving industry investment and by 11% in countries that did not. Over the same period cigarette consumption increased by 40%; the increase was concentrated in countries receiving investments. Despite these investments, cigarette imports still outweigh exports and no trade surplus has yet to result.

CONCLUSIONS

The findings suggest that liberalisation of inward investment has a significant and positive impact on cigarette consumption and that without appropriate safeguards, market liberalisation may have long term negative impacts on health. Specific trade rules are needed to govern trade and investment in this uniquely harmful product. Implementation of effective tobacco control policies should precede tobacco industry privatisation. International financial organisations pressing for privatisation should ensure this occurs.

Determinants of smoking in eight countries of the former Soviet Union: results from the living conditions, lifestyles and health study

AIMS

To provide accurate and timely data on the determinants of smoking in countries of the former Soviet Union in order to facilitate the development of effective tobacco control policies in the region. Such data are urgently needed given the absence of accurate comparative data in the region and the recent changes experienced.

DESIGN

Cross-sectional surveys using standardized methods and representative samples of the adult population in eight former Soviet Union countries conducted as part of the EU-Copernicus Project Living Conditions, Lifestyle, and Health study.

SETTING

Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine.

PARTICIPANTS

A total of 18 428 adults aged 18 plus; response rates 71-88%.

MEASUREMENTS

The association of smoking with demographic and socio-economic factors was investigated using multiple logistic regression analyses, stratifying by gender.

FINDINGS

Age was a strong determinant of smoking in both genders, with elderly individuals being less likely to smoke. Men who were more socially disadvantaged (less educated, poorer economic situation and/or less social support) were more likely to smoke. In women, living in larger urban areas was the strongest predictor of smoking. Divorced, separated or widowed women were also more likely to smoke than married women. Muslim respondents smoked less frequently compared with other respondents.

CONCLUSIONS

Smoking is a major public health issue in the FSU particularly affecting socially vulnerable men and young women living in urbanized areas. These high-risk groups should be targeted in future smoking prevention and cessation strategies in the region.

Prevalence of smoking in 8 countries of the former Soviet Union: results from the living conditions, lifestyles and health study

OBJECTIVES

We sought to provide comparative data on smoking habits in countries of the former Soviet Union.

METHODS

We conducted cross-sectional surveys in 8 former Soviet countries with representative national samples of the population 18 years or older.

RESULTS

Smoking rates varied among men, from 43.3% to 65.3% among the countries examined. Results showed that smoking among women remains uncommon in Armenia, Georgia, Kyrgyzstan, and Moldova (rates of 2.4%-6.3%). In Belarus, Ukraine, Kazakhstan, and Russia, rates were higher (9.3%-15.5%). Men start smoking at significantly younger ages than women, smoke more cigarettes per day, and are more likely to be nicotine dependent.

CONCLUSIONS

Smoking rates among men in these countries have been high for some time and remain among the highest in the world. Smoking rates among women have increased from previous years and appear to reflect transnational tobacco company activity.

Does the association between ill health and unemployment differ between young people and adults? Results from a 14-year follow-up study with a focus on psychological health and smoking

OBJECTIVES

Research has given a comprehensive picture of the negative health consequences of unemployment without offering sufficient comparison between different age groups. The aim of this study was to analyse whether the associations between ill health, particularly poor psychological health and smoking, and unemployment differ between young and adult men and women.

STUDY DESIGN

A 14-year follow-up study of graduates of compulsory school in an industrial town in northern Sweden was undertaken. The subjects were analysed at ages 16, 21 and 30 years. Complete data on the cohort were collected for 1044 individuals with the aid of a comprehensive questionnaire. The response rate was 96.4%.

METHODS

The main health measurements used in this study were poor psychological health and smoking, analysed by multivariate logistic regression.

RESULTS

After controlling for several background variables, associations between long-term unemployment and poor psychological health were found in young men and women, and adult men. Long-term unemployment was only associated with smoking in young people.

CONCLUSIONS

The association between long-term unemployment and psychological health, as well as smoking, seemed to be stronger in young people than adults.

Prevalence and determinants of smoking in Tirana city, Albania: a population-based survey

BACKGROUND

Smoking is the leading cause of premature death in Europe yet there are still many countries in which there is little information on its patterns and determinants. Albania is one such country.

METHODS

A survey of health and lifestyle, including questions on smoking practice and attitudes, and its determinants was undertaken in Tirana, the capital of Albania in mid 2001.

SUBJECTS

One thousand one hundred and twenty adults aged 25 years and over (response rate 72.7%).

RESULTS

Forty-one percent of the study population (61% male and 24% female) were current or ex-smokers-28% were current smokers (37.6% of males and 19.3% of females) and 13% were ex-smokers (23.4% of males and 4.7% of females). Age-standardized (to the European standard population) prevalence of smoking for the adult population of Tirana was 31.2% (42.8% in males and 21.2% in females). Smoking was most common among those aged 25-34 years (59% of males and 30% of females in this age group). Of the current smokers, 16.5% smoked more than 20 cigarettes/day, and 67.3% smoked the first cigarette within 30 min of waking. Only 11% of current smokers had tried to quit smoking once during their life. Concern about health was the most common reason for quitting cited by ex-smokers (44%). In men, smoking was inversely associated with educational achievement. While the probability of smoking decreases with age, there was no consistent association with employment or income.

CONCLUSION

The prevalence of smoking in Albania is comparable with other Western societies. The high rates of smoking among young men and women suggest that tobacco will make an increasingly large contribution to premature morbidity and mortality in the future. The high rate of smoking among young women in Albania, while a common phenomenon in post-communist countries, is especially worrying. This study emphasizes the need for a robust, evidence-based strategy for tobacco control in Albania.

Determinants of and inequalities in self-perceived health in Ukraine

Ukraine is the second most populous of the former Soviet Republics and since transition its economy has fared even more poorly than Russia. Although the impact of the collapse of the former Soviet Union on health in Russia has been investigated, little is known of its impact in other post-Soviet republics. We report a cross-sectional study undertaken in Ukraine in March 2000. A multi-stage random sampling technique was used and 1600 interviews completed (72% response rate) with a representative national sample of Ukrainian adults. We investigated socioeconomic and psychosocial determinants of self-perceived health, which has been shown to be a valid and reliable measure of overall health and predictive of mortality. Odds ratios for less than good physical health were calculated using logistic regression. The self-rated health of Ukrainians was poor, 25% of men and 43% of women rated their health as poor or very poor. This is worse than levels recorded in Russia and considerably worse than levels seen in western Europe. Marked gender, geographical and socioeconomic inequalities in health were recorded. Women are at increased risk of poor self-rated health compared with men (OR 3.58, 2.50-5.14) as are women living in villages compared with those in cities (OR 3.24, 1.30-8.07). Socioeconomic factors including poor material situation (OR 1.64, 1.01-2.67), and psychosocial factors including low control over life (OR 1.89, 1.15-3.11) were identified as independent health determinants. Control over life was found to account for the negative impact of low social position on health. Good family relations protected against poor health. The findings suggest that a decrease in control, arising from an increasingly uncertain political and economic environment, a reduction in material wealth and the stress of change may all have contributed to the decline in life expectancy seen with transition.