Developing Countries

The global distribution of tobacco consumption is increasingly inequitable, meaning that the diverse social, economic, and health impacts are increasingly borne by developing countries. A marked shift in smoking patterns is occurring. As the percentage of people who smoke has been decreasing in most high-income countries over recent decades, it has been increasing substantially among low- and middle-income countries (LMICs). These countries already account for 82 percent of the world's smokers (Gajalakshmi et al. 2000). This change in smoking patterns is being followed by a change in patterns of tobacco-related disease and death. Around 4.9 million deaths were attributable to tobacco use worldwide in 2000, an increase of 45 percent since 1990, with the most rapid increase seen in developing countries which now account for 50 percent of these deaths (World Health Organization 2002). It is predicted that by 2030 the global total of annual tobacco related deaths will reach 10 million, or around one in six adult deaths; 70 percent of these deaths will occur in developing countries (Gajalakshmi et al. 2000).

Broader social and economic changes associated with globalization have facilitated this shift in smoking patterns, as have international agreements designed to free or liberalize trade. The opening of cigarette markets in LMICs to Western-based transnational tobacco companies is emerging as critical to the development of the global industry and has provided a foundation for the spread of the tobacco epidemic. The transnational tobacco companies, led by Philip Morris and British American Tobacco, targeted markets in Latin America in the 1970s and Asia in the 1980s. More recently countries in the former Communist bloc have been targeted including those in Central Asia, plus Africa, and the world's largest market, China. The impact of expansion into these markets is illustrated by research into the opening of the markets of Japan, South Korea, Taiwan, and Thailand following the threat of trade sanctions by the United States. It is estimated that the opening of these markets increased per capita cigarette consumption by an average of 10 percent by 1991 (Chaloupka and Laixuthai 1996).

Whether viewed from a health or a development perspective, it is important to note that while trade liberalization has led to increased consumption of tobacco overall, the distribution of this rise has been uneven. There has been no substantive effect on consumption in high-income countries, but trade liberalization has had a large and significant impact on smoking in low-income countries and a significant, if smaller, impact on middle-income countries (Taylor et al. 2000). Such differential impacts seem likely to have further implications for health equity, with developing countries again assuming a disproportionate burden.

Consumption Patterns

Despite these core trends in the global tobacco epidemic, consumption patterns among developing countries remain diverse, differentiated for example by region, gender, and product. Consumption is estimated to be highest in the Western Pacific, driven by the high rates in the Chinese market, and lowest in Africa, particularly sub-Saharan Africa (Gajalakshmi et al. 2000). The few reliable data do, however, indicate that smoking in Africa is rising significantly, particularly among the young (Shafey et al. 2003).

In contrast with the broad convergence of male and female smoking prevalence across much of Europe and North America, huge disparities in tobacco use by gender remain in many developing countries. Whereas the World Bank estimated smoking prevalence among men and women in high-income countries at 38 percent and 21 percent respectively, in LMICs these figures were 49 percent among men and 9 percent among women (Gajalakshmi et al. 2000). A particularly stark example is provided by China, where adult male smoking prevalence of 53 percent contrasts with only 4 percent among women.

The magnitude of difference in male and female consumption among developing countries does, however, need to be qualified. In many countries cultural barriers have traditionally served to prohibit smoking by women. Current figures are likely to underestimate actual tobacco use among women, due to under-reporting. More significantly, the primary emphasis on cigarette smoking ignores traditional widely practiced noncommercial forms of tobacco use. In India, for example, female cigarette use in urban centers is confined to between 2 percent and 5 percent, whereas up to 67 percent of rural women use chewing tobacco (Samet and Yoon, eds. 2001). It is also anticipated, especially in Asia, that increasingly targeted marketing by transnational tobacco companies, in combination with broader socioeconomic changes, are likely to lead to significant increases in smoking prevalence. Such increases among women have been reported in Cambodia, Malaysia, and Bangladesh (Shafey et al. 2003).

Varieties of Tobacco Consumed

In contrast to the almost exclusive use of manufactured white-stick cigarettes in the West, tobacco consumption in a variety of forms continues in developing countries. Bidis, which are typically hand-wrapped in temburni leaf and tied with string, deliver high levels of tar and carbon monoxide. This form of tobacco is commonly used in much of South East Asia, and in India seven are sold for every one cigarette. In Indonesia, consumption is predominantly of kreteks, a form of cigarette that blends tobacco with cloves. The latter ingredient gives off eugenol, which has an anesthetizing effect leading to deeper inhalation and high tar yields. The use of smokeless tobacco, predominantly chewing tobacco, is also widespread across much of South, Southeast, and Central Asia, North Africa, and the Eastern Mediterranean where tobacco is chewed in combination with a wide range of sweet flavorings. Additional regionally significant forms of tobacco use include the water pipe (shisha, hookah, or hubbly bubbly), which is common in many countries of North Africa, the Mediterranean, and parts of Asia; and the clay pipe (chillum or hookli) in South East Asia (Mackay and Eriksen 2002).

Health Impacts of Tobacco Use

Because of the cost and complexity of organizing epidemiological research, most of the evidence on the health impacts of tobacco use comes from high-income countries. Recent studies from China and India, however, suggest that although the overall risks of smoking are about as great as in high-income countries and the diseases caused by smoking are similar, the specific pattern of smoking-related diseases may differ (Chen et al. 1997; Gupta and Mehta 2000; Gajalakshmi et al. 2000). This occurs for a number of reasons including the type of tobacco used (with oral cancers more common in populations using smokeless tobacco), its tar and nicotine yields, the age of first smoking, the presence and prevalence of other etiological and infective agents with which smoking may interact (Stewart 2003), the stage of the tobacco epidemic, and variations in underlying causes of illness.

The effects of smoking can kill by making diseases that are already common more so. In most developing countries, the epidemic is in a relatively early stage and the full impacts of tobacco on population health have yet to be realized. A key issue for countries yet to complete the epidemiological transition from external to internal causes of death is the additional burden of disease that tobacco will cause at a time when infectious and other causes of death have yet to decline.

Tobacco Cultivation

Cultivation of tobacco leaf is increasingly dominated by LMICs, with China, India, Brazil, Turkey, Zimbabwe, Indonesia, and Malawi all among the world's top ten producing nations in 2001. Tobacco is grown in over 125 countries, though substantial economic dependence on the crop is far less common; it accounts for over 1 percent of total export earnings in only 18 countries and for over 5 percent in just 4, namely Kyrgyzstan, Macedonia, Zimbabwe, and Malawi (at 8%, 16%, 32%, and 58% respectively) (Campaign for Tobacco Free Kids 2001).

The prominence of LMICs among tobacco producers has, however, been used by the tobacco industry to present tobacco control initiatives as antithetical to development. An examination conducted for the World Health Organization of industry documents made available via litigation revealed the scale of efforts to portray such activities as a "First World" agenda carried out at the expense of developing countries. Documents have identified the explicit use of the International Tobacco Growers Association as a front group for industry lobbying. This organization has made concerted efforts to stop developing countries from becoming committed to tobacco control, to divide the World Health Organization from other United Nations agencies and restrict its funding, and to create an international consortium to mobilize officials from developing countries to advance pro-tobacco positions (Zeltner et al. 2000).

Impact of Tobacco Controls

Increasing evidence illustrates the potential contribution of tobacco control to development. Research in Bangladesh has demonstrated how expenditure of household income on tobacco can worsen poverty and diminish living standards among the poor. In Bangladesh, the poorest households are twice as likely to smoke as the wealthiest, and close to 10.5 million people currently suffering from malnutrition could have an adequate diet if such expenditure were spent on food instead (Efroymson et al. 2001).

As a result of research led by the World Bank, it is increasingly clear that, for the vast majority of developing countries, increased taxation of tobacco products would not cause long-term job losses. Tobacco control actually presents policy makers with a virtuous circle, combining substantial benefits for public health through reduced consumption with an expansion in revenues via increased taxation. It is also worth noting that improved tobacco control is not going to result in a sudden collapse in demand for these products. Indeed the number of people using tobacco products is expected to increase by more than 500 million during the first quarter of this century (World Bank 1999).

Tobacco Control Policies

The later onset of the tobacco epidemic among developing countries, the complex and competing health priorities, and the continuing influence of the tobacco industry are reflected in generally weaker health regulation. This general pattern is, however, punctuated by a number of states with comprehensive legislation including Thailand, Singapore, and South Africa.

The recent completion of negotiations for the World Health Organization's first public health treaty, the Framework Convention for Tobacco Control (FCTC), raises the opportunity for a broader expansion of regulation across developing countries. A distinguishing feature of the negotiations was the prominent role played by the African and South East Asian regions, their impact heightened by adopting regionally coordinated positions. These combined a powerful commitment to tobacco control, including calls for the FCTC to take priority over trade agreements, with demands for financial resources to assist diversification for countries dependent on tobacco production (Shafey et al. 2003). Nevertheless, there remains an urgent need for implementation and enforcement of effective tobacco control policies in most developing countries.

? JEFF COLLIN

? ANNA B. GILMORE

BIBLIOGRAPHY

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bidis thin, hand-rolled cigarettes produced in India. Bidis are often flavored with strawberry or other fruits and are popular with teenagers.

temburni leaf a leaf used to wrap bidis cigarettes.

tar a residue of tobacco smoke, composed of many chemical substances that are collectively known by this term.

kretek a clove cigarette, originally of Indonesian origin.

eugenol an aromatic chemical derived from cloves. It is the active ingredient found in clove cigarettes.

epidemiological pertaining to epidemiology, that is, to seeking the causes of disease.

etiological concerned with the origins of disease.

diversification in agriculture, avoidance of overdependence upon one crop by producing several different crops.