children ’ s exposure to environmental smoke / involuntary smoking in developing countries:...
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Children’s Exposure to Environmental Smoke / Involuntary Smoking in Developing Countries: Current Situation and Implications for Health and Development
Enis Barış
and
Ayda A. Yürekli
World Bank,
Washington, D.C.
OutlineOverview Health effects Determinants of ETS
Review of evidence on determinants from developing countriesEstimation of exposure to ETS by level of income and regionsRecommendations
Lack of Access to Clean Air and Child Health
According to WHO, 700 million children around the world were exposed to second hand smoke in 1999. Lack of clean air is associated with lower respiratory tract infections middle ear disease chronic respiratory symptoms asthma decreased lung function sudden infant death syndrome (SIDS).
Source: WHO/TFI: International Consultation on ETS and Child Health, 1999
Determinants of ETS Exposure
The intensity of exposureThe number of smokersThe extent of cigarette consumptionThe behavior of smokers
Legislation that restricts smoking in public and work places and its enforcement.
In Developing Countries
Same negative health effects But of different magnitude due to variation in the relative importance of exposure
determinants, mostly smoking behavior legislation prevailing social norms and ecology, and
as a result of different health and socioeconomic impact in terms of
health consequences (nutrition, co-morbidity) healthcare costs absenteeism societal response (tolerance, compliance, complacency, etc)
Intensity of ExposureNumber of smokers around the globe
2000
Number of Smokers by Income Groups
17%11%
44%
27%
0
100
200
300
400
500
600
LI LMI UMI HI
# of s
mok
ers,
Mill
ion
1.2 billion smokers globally 83% of global smokers (956 million) live in developing countries Prevalence
rate (in 90s)Male Female
Bangladesh 40 10
Turkey 59 26
Vietnam 73 4
Pakistan 36 9
China 63 4
Indonesia 63 2
Russia 63 14
Philippines 75 18
Egypt 43 5
Prevalence rate in selected developing countries
Intensity of ExposureGlobal Cigarette Consumption 2000
In 2000, 6.2 Trillion Cigarettes Smoked Worldwide.Developing Countries Smoked 74% of Global Cigarette
Consumption (4.6 Trillion Cigarettes)
Global cigarette consumption
6260 billion pieces
26%
10%
44%
21%
0
500
1000
1500
2000
2500
3000
LI LMI UMI HI
Billion of cigarettes and % share in the globe
Consumption (mil. pieces)
% global share
LI 1295 21
LMI 2733 43
UMI 613 10
HI 1619 26
Total 6260 100
China 1688 27
India 947 15
LI w/o India 348 6
LMI w/o China 1045 17
Intensity of ExposureDaily Smoke
Daily 11 to 21 sticks smoked by smokers
Daily cigarette consumption per smoker in 2000
11
1412
21
0
5
10
15
20
25
LI LMI UMI HI
Smokers’ smoking behavior: Evidence from Indonesia 1995
National Health Survey 1995
# of Total HH 31,126,882
# of HH member 109,154,973
# of smoker 38,652,636
# of smoker smoke
at home 36,888,636
Average
HH member 3.51
Smoker per HH 1.24
Smoker smoke at home 1.18
# of cigarettes smoked/day 11 pieces
Estimated ETS Exposure% of smokers smoke at home 95.4%
Average non-smoker per household 2.26
% of HH members exposed to ETS 65%
Source: Authors’ estimate based on National Health Survey data, 1995
Smokers’ smoking behavior:Evidence from Turkey
% of smokers who smoke at home and in front of children in Ankara, Turkey
90% 97%87% 84%
100%
63%
85%
60%49%
77%
Teachers Mothers Journalist Physicians Parliamentarians
At home Front of children
Source: Bilir, N et al. 1997. Smoking behavior and attitudes, Ankara, Turkey
High ETS Exposure Among 13-15 Year Olds in Selected Low and Low-middle Income Countries
% children exposed % children exposed
LMI At home
At public places
At home
At public places
Indonesia 69 84 China 54 51
Philippines 58 75 India 59 67
Jordan 67 61 Nepal 36 47
Russia 55 73 Nigeria 34 50
Bolivia 46 62 Sri Lanka 56 68
Venezuela 44 48 Ukraine 49 72
Uruguay 64 79 Zimbabwe 35 58
Source: GYTS Survey Data, 1999-00-01
Smoking restrictions in various places
Countries HC Facilities
Education
Facilities
Buses Waiting areas
Entertainment centers
Shopping centers
China B B B B B B
Philippines N N N N N N
Thailand B D B D B B
Iran B B B B B B
Turkey D D D D D D
Poland D D N D D D
Indonesia B B D N N N
Nigeria B B B N N N
Malaysia B B B B B B
B: banned, N: None, D: Designated areas
Source of Data
Nations: Prevalence rates
USDA: Cigarette consumption
WBI: Children and adult population
GYTS: ETS exposure among 13-15 y of age
Percentage of 1.8 billion children aged 0-14 years living in developing
countries, 2000
0-14 yrs old population (mil)
% share in total pop.
% share in global child population
Low Income 842 37% 47%
Low Middle Income 628 27% 35%
Upper Middle Income 172 29% 10%
High Income 162 18% 9%
LI and LMI 1,471 32% 82%
All Developing 1,642 33% 91%
Developed 162 18% 9%
Total 1,805 31% 100%
Source: WBI and Authors’ calculation
Children (0-14 years old ) and ETS exposure Selected countries with the highest child population and
ETS exposure, 2000
Total (0-14 age) child pop. (Million)
% share in global 0-14 age child population
% of ETS Exposure 13-15 years old students
Home Public Places
India 340 18.9 59 67
China 314 17.4 54 51
Indonesia 65 3.6 9 84
Pakistan 58 3.2 N/A N/A
Nigeria 57 3.2 34 50
Philippines 28 2.6 58 75
Vietnam 26 1.5 N/a N/a
Russia 26 1.4 55 73
Total 994 55 N/A N/A
Top 10 countries w/highest child population and ETS exposure
0-14 age population
% share in global 0-14 age
% of 13-15 age exposed to ETS
Home Public
India 340 18.9 59 67
China 313 17.4 54 51
Indonesia 65 3.6 69 84
Pakistan 58 3.2 N/A N/A
Nigeria 57 3.2 34 50
Bangladesh 51 2.8 N/A N/A
Ethiopia 29 2.6 N/A N/A
Philippines 28 2.6 58 75
Vietnam 26 1.5 N/A N/A
Russia 26 1.4 55 73
Total 0-14 pop.(top 10) 944 55.0
Global 0-14 pop. 1805
Source: WBI & GYTS
Over 900 million children living in developing world were exposed to ETS in
2000.
Source: World Bank Estimation
Number of Children (0-14 age) exposed to ETS at home and public places, 2000
(Million)
461
365
99
925
379
371
84
834
LI
LMI
UMI
TOTAL
# exposed at public places # exposed at home
Percentage of children 0-14y of age exposed to ETS at home in developing
countries, 2000
Income Groups
# of exposed children at home
in developing world (million)
% share within
income group
% share in developing
world
% share globally
LI 380 48% 23% 21%
LMI 371 55% 22% 20%
UMI 84 44% 5% 4%
Total 837 46%
Source: Authors’ calculation
Percentage of children 0-14y of age exposed to ETS in public places in developing countries, 2000
Income Groups
# of exposed children in public
places in developing world
(million)
% share within
income group
% share in developing
world
% share globally
LI 461 59% 28% 26%
LMI 365 53% 21% 20%
UMI 99 57% 7% 6%
Total 925 51%
Authors’ calculation
Top 10 UMI countries with the highest number of children exposed to ETS at
home and public places Region Country # of children
exposed to ETS at home (mil)
# of children exposed to ETS in public places (mil)
LAC Brazil 25 32
LAC Mexico 17 21
ECA Turkey 12 11
AFRICA S. Africa 6 8
LAC Argentina 5 7
EAP Korea Rep. 5 6
ECA Poland 5 5
MENA S. Arabia 5 6
LAC Venezuela 4 5
EAP Malaysia 4 5
Top 10 LMI countries with the highest number of children exposed to ETS at
home and public placesRegion Country # of children
exposed to ETS at home (mil)
# of children exposed to ETS in public places (mil)
EAP China 171.0 166.0
EAP Indonesia 35.2 34.2
SA Pakistan 32.2 21.9
MENA Iran 16.0 14.6
EAP Philippines 15.4 15.0
MENA Egypt 15.2 13.9
ECA Russia 14.4 18.9
EAP Thailand 8.8 8.6
MENA Morocco 6.7 6.1
MENA Iraq 6.5 5.9
Top 10 LI countries with the highest number of children exposed to ETS at
home and public placesRegion Country # of children
exposed to ETS at home (mil)
# of children exposed to ETS in public places (mil)
SA India 199.0 227.8
SA Bangladesh 29.7 34.0
AFRICA Nigeria 18.4 27.6
EAP Vietnam 14.0 13.3
AFRICA Ethiopia 9.3 14.0
EAP Myanmar 8.5 8.1
AFRICA Congo Dem.Rep. 8.0 12.0
SA Afghanistan 6.8 7.7
MENA Yemen 5.9 3.6
SA Nepal 5.5 6.3
Results91% of global children aged 0-14 years live in developing world.
83% of global smokers (956 million) live in developing countries.
In 2000, developing countries smoked 74% of global cigarette consumption (4.6 trillion cigarettes).
Lower number of cigarettes smoked per capita.
Still high rate of ETS exposure at homes and public places: Over 800 million children are exposed to ETS at homes and
900 million in public places in developing countries.
Most smokers still smoke near non-smokers and/or in front of children.
Conclusion: Worrisome Trends and Patterns
Exposure of children to ETS is larger than previously estimatedExposure is equally significant in homes and public places, although this varies depending on legislation and social normsExposure is likely to become more significant as: Women take up smoking Countries develop and economies grow
Exposure is likely to be more hazardous due to other factors, e.g. poverty, other indoor pollutants, nutritional deficiencies, etc.
Conclusion: Policy Implications
Implementation of Framework Convention on Tobacco Control, including legislative initiatives inclusive of ETS;Higher taxes, especially where price elasticity is higher; and Involvement of professional associations (teachers, doctors, police force), women’s groups, athletes, etc to mobilize social elites to challenge and change prevailing social norms and enforce existing laws and ordinances.More comprehensive public health action, bundled with IAP and other initiatives.
Conclusion: Research ImplicationsThere is a need to:
Identify culture-specific determinants of ETS amenable to interventions, including risk perception and communication;Pilot innovative programs involving role models (teachers, mothers, athletes, etc.) and targeting home environments;Estimate ETS attributable burden of disease and health care costs in developing countries;Document and cost non-health related effects of ETS, e.g. absenteeism from school, work, etc; andSeek synergism with other development issues such as IAP due to coal, biomass use, etc.