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Prevalence of Smoking in 8 Countries of the Former Soviet Union: Results
The Living Conditions, Lifestyles and Health Study
SOURCE: American Journal of Public Health 94 no12 2177-87 December 2004
Anna Gilmore, MSc, MFPH
Joceline Pomerleau, PhD, MSc
Martin McKee, MD, FRCP
Richard Rose, DPhil, BA
Christian W. Haerpfer, PhD, MSc
David Rotman, PhD
Sergej Tumanov, PhD
ABSTRACT
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. (Am J Public Health.
2004;94:2177-2187)
In 1990, it was estimated that a 35-year-old man in the former Soviet
Union had twice the risk of dying from tobacco-related causes before the age
of 70 years as a man in the European Union (20% vs 10%).(FN1) In the former
Soviet Union, 56% of male cancer deaths and 40% of all deaths are attributed
to tobacco, compared with 47% and 35%, respectively, in the European
Union.(FN1) Rates of circulatory disease among both men and women are
approximately triple those in the European Union.(FN2) Moreover,
tobacco-related mortality continues to increase in the former Soviet Union,
while it has stabilized or declined in the European Union as a whole.(FN1)
Despite these deplorably high levels of tobacco-related mortality,
relatively little is known about smoking prevalence rates in the region.
Virtually no recent or reliable data exist for the central Asian countries
(Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan),(FN2,3)
and recent surveys conducted in Georgia have been limited to the capital,
Tbilisi.(FN4,5) Data from elsewhere in the Caucasus (Armenia, Azerbaijan)
are scarce,(FN6) and historical figures(FN7) are inconsistent with later
findings, leading authors to rely on anecdotal reports of smoking
rates.(FN8).
Historical(FN3) and more recent data, derived largely from Russia,(FN9)
Ukraine,(FN10) Belarus,(FN11) and the Baltic states,(FN12) show-perhaps
unsurprisingly, given the mortality figures just described-that smoking
rates among men are high (45%-60%) while rates are far lower among women
(1%-20%).(FN2) The higher rates previously seen among Estonian women are now
being matched by rates among women in the other Baltic states (FN2,12,13)
and by women in other urban areas.(FN9,10) Unfortunately, other than the
Baltic states, few countries collect information using similar data
collection tools, thereby precluding accurate between-country comparisons.
These issues underlie the need in the former Soviet Union for comparable
and accurate data on smoking prevalence, given that such data are widely
recognized as a prerequisite for the development of effective public health
policies.(FN14-16) This need is made more urgent by the profound changes
occurring as a result of the former Soviet Union's recent economic
transition and, more specifically, by the changes taking place in its
tobacco industry.(FN17) The latter were first felt as soon as these formerly
closed markets opened, with a rapid influx of cigarette imports and
advertising.(FN18-20) Later, as part of the large-scale privatization of
state assets, most of the newly independent states privatized their tobacco
industries, and the transnational tobacco companies established a local
manufacturing presence, investing more than $2.7 billion in 10 countries of
the former Soviet Union between 1991 and 2000.(FN21) Evidence from the
industry's previous entry into Asia suggests that these changes are likely
to have a significant upward impact on cigarette consumption.(FN22,23)
In response to these and other health and social issues facing the
region, a major research project-the Living Conditions, Lifestyles and
Health Study-was commissioned as part of the European Union's Copernicus
program. This investigation involved surveys conducted in 8 of the 15 newly
independent states: Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan,
Moldova, Russia, and Ukraine.(FN24) We present data on smoking prevalence,
including age-and gender-specific smoking rates, age at initiation of
smoking, and indicators of nicotine dependence.
METHODS
Study Population and Sampling Procedures
In autumn 2001, quantitative cross-sectional surveys were conducted in
each country by organizations with expertise in survey research using
standardized methods(FN25) (described in detail elsewhere(FN26)). In brief,
each survey sought to include representative samples of the national adult
population 18 years or older, although a few small regions had to be
excluded as a result of geographic inaccessibility, sociopolitical
situation, or prevailing military action: Abkhazia and Ossetia in Georgia,
the Transdniester region and the municipality of Bender in Moldova, the
Chechen and Ingush republics, and autonomous districts located in the far
north of the Russian Federation.
Samples were selected via multistage random sampling with stratification
by region and area. Within each primary sampling unit, households were
selected according to standardized random route procedures; the exception
was Armenia, where household lists were used to provide a random sample.
Within each household, the adult with the birthday nearest to the date of
the survey was selected to be interviewed. At least 2000 respondents were
included in each country; 4006 residents of the Russian Federation and 2400
residents of Ukraine were interviewed, reflecting the larger and more
diverse populations of these countries.
Questionnaire Design
The first draft of the questionnaire was created, in consultation with
country representatives, from preexisting surveys conducted in other
transition countries(FN9,10,12) and from New Russia Barometer surveys(FN27)
adjusted to national contexts. It was developed in English, translated into
national languages, back-translated to ensure consistency, and pilot tested
in each country. Trained interviewers administered the questionnair in
respondents' homes.
Statistical Analyses
Stata (Version 6; Stata Corp, College Station, Tex) was used to analyze
the data. As a means of reducing the skewness of their distribution, the
continuous variables of age at smoking initiation and smoking duration were
transformed, via log-normal transformations, before analyses were conducted;
however, they were returned to their original units in computing results.
Current smokers were defined as respondents reporting currently smoking
at least 1 cigarette per day. We calculated age-and gender-specific smoking
prevalence rates for each country. Given the negative health effects of
early initiation, we examined age at smoking initiation among current
smokers, as well as number of cigarettes smoked. We assessed level of
nicotine dependence, an indication of smokers' ability or inability to quit,
by identifying the percentage of current smokers who smoked more than 20
cigarettes per day and smoked within an hour of waking. This level of use is
equivalent to a score of 3 or more on the abbreviated Fager-strom dependency
scale(FN28,29) and indicates moderate (score of 3 or 4) to severe (score of
5 or above) dependency.
Within each country, gender differences in smoking habits were assessed
with x[sup2] tests and 2-sample t tests; variations according to age group
were estimated via logistic regression analyses in which the 18-to 29-year
age group was the reference category. Logistic regression analyses with
Russia as the baseline were used in making between-country comparisons in
likelihood of smoking, while analyses of variance combined with Bonferroni
multiple comparison tests were used in comparing geometric mean ages at
smoking initiation. To allow for the large number of comparisons, we used
99% confidence intervals and set the significance level at .01.
RESULTS
Response Rates
A total of 18428 individuals were surveyed. Response rates (calculated
from the total number of households for which an eligible person could be
identified) varied from 71% to 88% among the countries included. Rates of
nonresponse for individual items were very low (e.g., 0.03% for current
smoking and 0.5% for education level).
Sample Characteristics and Representativeness
The samples clearly reflected the diversity of the region and were
broadly representative of their overall populations (Table 1). Comparisons
of the present data and official data are potentially limited by the failure
of some of the country data to fully capture posttransition migration and
other factors,(FN30) but they suggest slight underrepresentations of men in
Armenia and Ukraine, of the urban population in Armenia, and of the rural
population in Kyrgyzstan. Age group comparisons among the respondents 20
years or older suggested a tendency for the oldest age group to be
overrepresented at the expense of the youngest age group, particularly in
Armenia, Moldova, and Ukraine.
Smoking Prevalence
Rates of male smoking were high. In many of the countries surveyed,
almost 80% of male respondents reported a history of smoking (Table 2).
Rates of current smoking were lowest in Moldova (43.3%) and Kyrgyzstan
(51.0%) and highest in Kazakhstan (65.3%), Armenia (61.8%), and Russia
(60.4%). Smoking rates in Russia were not distinguishable from those in
Kazakhstan, Armenia, or Belarus but were significantly higher than those
observed in Moldova, Kyrgyzstan, Ukraine, and Georgia (P<.01; data not
shown).
Rates among women were far lower (gender comparisons were significant at
the .001 level in all countries) and somewhat more variable, ranging from
2.4% to 15.5%; the lowest rates were seen in Armenia, Moldova, and
Kyrgyzstan and the highest in Russia, Belarus, and Ukraine. Smoking among
women in Russia was significantly more prevalent than among women in all of
the other countries under study (P<.01) although adjusting for age removed
the difference between Russia and Belarus (data not shown).
The relationship between smoking and age varied by gender. Among men,
with the exception of those residing in Moldova, smoking prevalence rates
varied little between the ages of 18 and 59 years but then declined more
markedly in men above the age of 60 years (Table 2, Figure 1). This decline
with age was accounted for by increases in the older groups in terms of
percentages of former smolers and never smokers. Among women, the overall
trend was a decrease in reports of both current and former smoking with
increasing age; very low smoking rates were observed in the oldest age group
(rates of reported lifetime smoking varied from 0.8%-3.9%). However, closer
inspection of the data suggested that the countries could be divided into 2
groups. In the first group (Russia, Belarus, Ukraine, and Kazakhstan), rates
of current and ever smoking implied that initiation of smoking had increased
rapidly between generations, especially in the youngest age group (Table 2,
Figure 1). In the second group (Armenia, Georgia, Kyrgyzstan, and Moldova),
the age trends were less obvious and were nonsignificant (with the exception
of the comparison of the oldest and youngest age groups in Moldova).
TABLE 1-Characteristics of Samples and Countries in the Living
Conditions, Lifestyles and Health Study: 8 Countries of the Former Soviet
Union, 2001
Characteristic AR BY GE KZ
KG MD RU UA
Simple
Response rate, % 88 73 88 82
71 81 73 76
Gender
Male, % 40.3 44.1 45.7
44.4 45.0 45.1 43.5 38.8
Men aged [greater or equal] 20 y, 40.7 43.9
45.6 44.1 45.6 44.9 43.2 38.6
No. 2000 2000 2022 2000
2000 2000 4006 2400
Age group, y, %
20-29 15.4 16.9 13.9
21.9 26.7 14.5 16.5 14.6
30-39 21.6 19.2 20.3
25.8 26.0 20.1 19.3 16.4
40-49 24.0 21.6 21.9
21.5 21.4 23.1 20.9 17.9
50-59 11.1 14.5 16.3
12.0 10.1 16.4 15.4 15.5
[greater or equal]60 28.0 27.9
27.6 18.8 15.9 26.0 27.9 35.5
No. aged [greater or equal]20 1940 1922
1975 1890 1899 1945 3828 2324
No. aged 18-19 60 78 47 110
101 55 178 76
Interview location, %
State/regional capital 44.0 33.9 41.4
27.0 27.5 30.4 35.7 31.5
Other city/small town 17.0 34.8 15.6
25.4 13.5 11.6 37.1 36.4
Village 39.0 31.4 43.0
47.6 59.0 58.1 27.3 32.1
No. 2000 2000 2022 1850
2000 2000 4006 2400
Reported nationality, %
Nationality of country[supa] 97.3 80.1 90.2
36.3 68.6 76.7 82.4 77.7
Russian 0.8 12.1 1.3
41.5 18.0 7.7 ... 16.5
Other 1.9 7.8 8.5
22.1 13.5 15.7 17.6 5.8
No. 2000 1979 2021 1979
1997 1980 3967 2371
Education, %
Secondary education or less 49.1 49.4 33.8
35.7 48.3 52.2 43.2 44.2
Secondary vocational or some college 30.4 34.2 32.7
43.5 32.7 32.7 35.7 36.1
College 20.5 16.4 33.6
20.8 19.0 15.2 21.1 19.7
No. 1996 1984 1996 1995
1996 1984 4004 2381
Country data
Midyear population, 2001, thousands 3788 9971 5238 14821
4927 4254 144387 49111
Gross national product per capita, 2001, $ 560 1190 620 1360
280 380 1750 720
Men aged [greater or equal]20 y, 2000, % 47.5 45.4
46.4 46.6 47.9 46.3 45.3 44.8
Urban population, 2001, % 67.3 69.6 56.5
55.9 34.4 41.7 72.9 68.0
Age group, y, % of total [greater or equal] 20
20-29 23.2 19.3 20.6
26.0 30.5 23.1 19.6 19.4
30-39 24.2 20.3 21.1
23.7 24.7 20.3 19.6 19.0
40-49 22.5 21.5 19.5
21.4 19.6 22.7 22.4 19.8
50-59 10.3 12.6 12.7
10.9 9.0 13.6 13.3 14.2
[greater or equal]60 19.7 26.4
26.2 18.0 16.2 20.3 25.1 27.6
Unemployment rate, % [supc] 11.7 2.3 11.1
2.9 3.2 2.0 13.4 5.8
Tobacco industry state owned (SO) P SO P
P P SO P P
or privatized (P)
Foreign direct investment in tobacco 8 0 0
440 ... 0 1719 152.9
industry, end of 2000, $ millions[supd]
Foreign direct investment in tobacco 0.002 0.000 0.000
0.030 ... 0.000 0.012 0.003
industry per capita x 1000[supd]
Note AR=Armenia; BY=Belarus; GE=Georgia; KZ=Kazakhstan; KG=Kyrgyzstan;
MD=Moldova; RU=Russia; UA=Ukraine.
[supa]Mean Armenians in Armenia, Belarussians in Belarus, Georgians in
Georgia, Kazakhs in Kazakhstan, Kirghiz in Kyrgyzstan, Moldovans/Romanians
in Moldova, Russians in Russia, and Ukrainians in Ukraine.
[supb]Data sources were European Health for All Database, January 2003;
Population Division of the Department of Economic and Social Affairs of the
United Nations Secretariat.
[supc]In 1999 for Russia, 2000 for Armenia and Ukraine, and 2001 for the
other countries.
[supd]Data from Gilmore and McKee(FN21); these are minimum investment
figures.
[Table Omitted]
Age at Initiation
The majority of male smokers reported that they began smoking before the
age of 20 years, and, on average, a quarter reported that they began in
childhood (Table 3). Far fewer women reported beginning in childhood, and
sizable percentages began after the age of 20 years; for example, 86% of
women residing in Armenia and more than 40% of women residing in Georgia,
Kyrgyzstan, and Moldova reported that they initiated smoking after this age.
These gender differences were significant in all of the countries under
study.
Differences also were observed between countries; in Belarus,
Kazakhstan, Russia, and Ukraine, geometric mean ages at smoking initiation
were younger than 18 years among men and younger than 20 years among women,
compared with older ages at smoking initiation elsewhere. Overall,
between-country differences were significant for both women and men (P<.
001); however, Bonferroni multiple comparisons showed that there were
significant differences among women only in comparisons involving Armenia
and countries other than Georgia and Moldova (P< 01; data not shown). Among
men, significantly younger ages at initiation were observed in Russia and
Ukraine versus Armenia, Georgia, Kyrgyzstan, and Moldova; in Belarus versus
Armenia and Kyrgyzstan; and in Kazakhstan versus Kyrgyzstan (all P< 01; data
not shown).
Amount Smoked and Nicotine Dependence
Men were found to smoke more cigarettes than women, the majority of men
smoked 10 or more cigarettes per day, while most women smoked fewer than 10
per day.
Between-gender differences in percentages of respondents smoking more
than 20 cigarettes per day were significant only in the case of Belarus,
Kazakhstan, Russia, and Ukraine (P< 001).
The majority of smokers reported smoking their first cigarette within an
hour of waking, although, in all countries other than Georgia, a far higher
proportion of men than women did so (P< 01). Thus, men were more likely to
be moderately to severely dependent on nicotine, although gender differences
were significant only for Belarus, Kazakhstan, Russia, and Ukraine.
DISCUSSION
The surveys conducted in this study provide important new data on the
prevalence of yin in 8 countries representing more than four fifths of the
population of the former Soviet Union. In the case of some of these
countries, these data represent the first accurate, countrywide smoking
prevalence data reported. In addition, they provide some of the first truly
comparative data for countries of the former Soviet Union other than the
Baltic states,(FN31,32) and, because of the focus on obtaining accurate
information on sample characteristics, they offer advantages over data
available in public databases. Response rates were relatively high, and the
samples were broadly representative of the overall country populations.
TABLE 3-Smoking Characteristics of Current Smokers in 8 Countries of the
Former Soviet Union, 2001
AR,% BY,% GE,% KZ,% KG,% MO,%
RU,% UA,% All,[supa]% Between-Country
Compadson, p[supb]
Age at smoking initiation, y
Men
Mean age 18.5 17.4 18.2 17.6 19.1 18.2
17.0 17.2 17.9
Geometric mean age 17.8 16.6 17.7 17.1 18.6 17.6
16.2 16.2 17.2 <.001
<16 22.2 32.8 18.0 27.9 14.7 22.8
36.4 35.2 26.2
16-20 56.8 54.2 66.0 57.0 61.8 59.9
49.8 48.5 56.7 <.001
>20 21.0 13.0 16.0 15.1 23.5 17.3
13.9 16.3 17.0
No 447 430 400 502 408 347
993 435 3962
Women
Mean age 28.0 18.9 22.7 20.7 21.5 23.0
20.9 21.2 22.1 <.001
Geometric mean age 27.0 18.5 21.3 19.9 20.7 21.5
19.8 19.9 21.1
<16 0.0 20.0 18.5 15.4 12.5 22.9
13.1 15.1 14.7 <.001
16-20 14.3 56.7 38.5 50.6 43.8 22.9
52.6 57.2 42.1
>20 85.7 23.3 43.1 34.1 43.8 54.3
34.4 27.6 43.3
No 28 120 65 91 28 35
329 152 868
Between gender comparison <.001 .002 <.001 <.001 .002
<.001 <.001 <.001
in geometric mean age[supc]
Number of cigarettes
smoked daily
Men
1-2 1.8 3.4 1.9 4.5 15.4 8.2
2.4 4.6 5.3
Up to 10 18.7 32.3 12.7 30.9 50.1 43.3
24.6 25.4 29.8 <.001
10-20 51.4 50.5 63.3 48.0 28.7 37.4
52.2 53.5 48.1
>20 28.1 13.7 22.2 16.6 5.8 11.0
20.8 16.5 16.9
Odds ratio for likelihood 1.487 0.606 1.085 0.756 0.234
0.471 1.00 0.753
of smoking >20
cigarettes per day
P .002 .001 .539 .038 <.001
<.001 .049
No 498 495 482 579 449 390
1052 484 4429
Women
1-2 32.1 23.7 11.9 19.4 36.2 37.2
18.7 22.2 25.2
Up to 10 28.6 48.9 29.9 53.4 46.8 41.9
56.6 45.7 44.0 .065
10-20 32.1 25.2 46.3 23.3 17.0 18.6
19.8 26.5 26.1
>20 7.1 2.2 11.9 3.9 0.0 2.3
4.9 5.6 4.7
Odds ratio for likelihood 1.50 0.44 2.64 0.79 ...
0.46 1.00 1.15
of smoking > 20
cigarettes per day
P 0.602 0.199 0.032 0.672 ...
0.461 0.749
No. 28 135 67 103 47 43
348 162 933
Between gender comparison .015 .000 .053 .001 .090
.073 <.001 <.001
of % smoking >20
cigarettes per day[supd]
Time when usually smoke first
cigarette
Men
First 30 minutes 63.5 47.9 52.9 42.8 39.0 44.1
56.5 55.8 50.3
after awakening
First hour 24.9 40.4 34.0 46.6 39.4 38.2
34.3 33.3 36.4 <.001
after awakening
Before midday meal 4.6 6.9 5.0 5.0 7.1 6.7
4.7 6.0 5.7
After midday meal or 7.0 4.9 8.1 5.5 14.5 11.0
4.6 5.0 7.6
in the evening
Odds ratio for likelihood 0.77 0.77 0.67 0.86 0.37
0.47 1.00 0.83
of smoking in first hour
P .140 .129 .021 .394 <.001
<.001 .292
No. 498 495 480 579 449 390
1051 484 4426
Women
First 30 minutes 50.0 31.9 44.6 35.0 27.7 14.3
33.7 27.8 33.1
after awakening
First hour 14.3 28.9 30.8 27.2 31.9 38.1
32.0 32.1 29.4 .278
after awakening
Before midday meal 3.6 19.3 12.3 13.6 12.8 11.9
13.5 17.3 13
After midday meal 32.1 20.0 12.3 24.3 27.7 35.7
20.8 22.8 24.5
or in the evening
Odds ratio for 0.94 0.81 1.60 0.86 0.77
0.57 1.00 0.78
likelihood of smoking
in first hour
P .879 .307 .129 .505 .409
.092 .203
No. 28 135 65 103 47 42
347 162 929
Between gender comparison <.001 <.001 .014 <.001 .004
<.001 <.001 <.001
in % smoking in
first hour[supd]
Moderate to heavy nicotine
dependence (> 20 cigarettes
per day and smoking within
first hour of awakening)
Men 26.9 13.7 21.4 16.6 5.6 10.5
20.6 16.2 16.4 .000
Odds ratio for likelihood 1.42 0.62 1.05 0.77 0.23
0.45 1.00 0.74 0.8
of moderate to severe
dependency
P .005 .093 .142 .104 .000
.000 .042 .00
No. 498 495 477 579 449 390
1051 483 4422
Women 7.1 2.2 10.8 3.9 0.0 1.0
17.0 9.0 6.4 .139
Odds ratio for likelihood 1.49 0.44 2.34 0.78 ...
0.47 1.00 1.14 1.0
of moderate to severe
dependency
P .605 .197 .071 .669 ...
.473 .754 .3
No 28 135 65 103 47 42
347 162 929
Between gender .020 <.001 .045 .001 .097
.091 <.001 .001
dependency comparison[supd]
Note. AR = Armenia; BY = Belarus; GE = Georgia; KZ = Kazakhstan; KG
Kyrgyzstan; MD = Moldova; RU = Russia; UA = Ukraine.
[supa]Average, assuming the same number of respondents in each country.
[supb]Results of analyses of variance (geometric mean) and x[sup2] tests
(categorical variable) for mean age at smoking initiation; x[sup2] test for
no. of cigarettes smoked, time to first cigarette, and dependency.
[supc]Results of tests.
[supd]Results of x[sup2] tests.
Study Limitations
The underrepresentation of men in Armenia and Ukraine should not have
affected the gender-specific rates observed, but, as a result of the
urban/rural differences in the composition of the sample, prevalence rates
in Kyrgyzstan (where urban areas were overrepresented) may have been
overestimated, and prevalence rates in Armenia (where urban areas were
underrepresented) may have been underestimated. However, these discrepancies
were likely to affect only the data relating to female respondents.(FN9-11)
The age group disparities noted were minor but would tend to lead to
underestimates of smoking prevalence.
In addition, the surveys were based on self-reported smoking status;
there was no independent biochemical validation, and thus the smoking rates
observed may have been affected by reporting bias. Although there is concern
on the part of some that self-reports of smoking status may produce
underestimates of smoking levels, studies conducted in Western countries
suggest that this technique is sensitive and specific; they also suggest
that more accurate responses are provided in interviewer-administered
questionnaires than in self-completed questionnaires (FN33) The only study
conducted in the former Soviet Union that has addressed this issue showed
that among individuals claiming to be nonsmokers, 13% (48/368) of women and
17% (12/375) of men in rural northwestern Russia were in fact, according to
blood cotinine levels, likely to be smokers, compared with only 2% of men
and women in Finland (FN34) Given the far lower prevalence of smoking among
women, this had disproportionately large effects on reported rates of
smoking among women. Although our questionnaires were administered by
interviewers in respondents' homes, potentially making it more difficult for
respondents who smoked to deny doing so, we may have underestimated smoking
prevalence rates, particularly in the case of women residing m areas where
smoking re mains culturally unacceptable.
A final shortfall of the present study was the failure to measure
smokeless tobacco use, which is relatively common in parts of the former
Soviet Union, mainly Azerbaijan, Tajikistan, and Turkmenistan. However,
although chewing tobacco is used in some of the southern regions of
Kyrgyzstan, cigarettes are the main form of tobacco used there as well as in
all of the other countries in which surveys were conducted.(FN8,35)
Findings
The results of our study confirm that smoking rates among men in this
region are among the highest in the world and higher than the maximum rates
recorded in the United States at the peak of its epidemic; rates above 50%
were observed in all countries other than Moldova and reached 60% or more in
Armenia, Kazakhstan, and Russia Elsewhere in Europe, rates above 50% are
seen only in Turkey (51%) and Slovakia (56%), and worldwide fewer than 20
countries report rates of more than 60%.(FN6)
In the case of men, the lower prevalence of current smokers and higher
prevalence of never and former smokers among those 60 years or older
probably reflect the disproportionate number of premature deaths among
current smokers relative to never and former smokers However, a cohort
effect has been shown in the former Soviet Union, with those who were
teenagers between 1945 and 1953 carrying forward lower smoking rates because
cigarettes, like other consumer goods, were in short supply in the period of
postwar austerity under Stalin.(FN36,37) This cohort effect is also thought
to account for the unexpected current decline in male lung cancer deaths,
(FN36) which must be set against the overall rise in male tobacco-related
mortality(FN1) and, in particular increases in the already staggeringly high
number of cardiovascular deaths.(FN2)
In comparison with male smoking patterns, smoking among women is far
less common, vanes more between countries, and exhibits a different
age-specific pattern Although rates of lifetime smoking are below 4% among
individuals older than 60 years in all 8 countries, in the 4 countries with
the highest smoking rates among women (Belarus, Kazakhstan, Russia, and
Ukraine), smoking is now significantly more common among members of the
younger generations, risk ratios between the youngest and oldest age groups
range from 12.2 to 37.3, compared with a range to 1.0 to 5.5 in the other 4
countries.
Lopez et al.(FN38) outlined a 4-stage model of the patterns of a smoking
epidemic based on observations from Western countries In this model, such an
epidemic is described as involving an initial rise in male smoking followed
by a rise in female smoking 1 to 2 decades later, after which each plateaus
and then falls as a result of tobacco-related mortality, finally rising to a
peak decades later Our findings suggest that the former Soviet Union's
tobacco epidemic may have developed differently Male smoking has a long
history in this region The first accounts of tobacco smoking in Russia date
from the 17th century, (FN39) papirossi (a type of cigarette, popular in the
former Soviet Union, characterized by a long, hollow mouthpiece that can be
twisted before smoking) were first mentioned in 1844, (FN39) and cigarette
factories were first constructed later in the 19th century. (FN40,41)
Historical data on smoking(FN3) and high male tobacco-related mortality
rates(FN1) suggest that smoking among men has been at a high level for some
time and, contrary to the predictions of the 4-stage model just mentioned,
has failed to exhibit a postpeak decline.
Smoking among women remains relatively uncommon, and rates have been far
slower to rise than would be expected given male rates in the former Soviet
Union and trends observed in the West. Indeed, it appears that female rates
began to increase only in the mid-to late 1990s, when transnational tobacco
companies arrived with their carefully targeted marketing strategies
(FN18-20) Therefore, although the exact stage of the epidemic varies
slightly between the countries of the former Soviet Union, overall we
suggest that men have remained between stages 3 and 4, with high rates of
both smoking and mortality, while women in some countries are at stage 1 and
others at stage 2, the latter with more rapidly rising smoking rates
Although rates of cardiovascular disease have been increasing, this can
largely be explained by risk factors other than tobacco (including diet and
stress), and female lung cancer rates have yet to increase.
Comparisons between our results and previous data are problematic given
that much of the information that exists is fragmentary, of uncertain
quality, and rarely nationally representative This is particularly the case
in the central Asian and Caucasian states, although limited data from
Armenia and Moldova gathered between 1998 and 2001 suggest few changes in
smoking prevalence rates (FN2,6); data from Kazakhstan suggest small
increases from the 60% male and 7% female prevalence rates; recorded in
1996.(FN2) More data are available for Belarus, Russia, and Ukraine These
data suggest that smoking rates m men have changed little, (FN2,10,11,42)
although m Russia they appeared to rise between the 1970s and 1980s(FN2,3,7)
and into the mid-1990s, with little subsequent change Among women, rates
appear to have increased in all 3 countries, (FN2,11) and Russian data
suggest that although rates have been rising since the 1970s, increases were
most notable during the 1990s. (FN3,7,9,43)
Between-gender and intercountry differences in smoking prevalence rates
are relater in other smoking indicators as well; for example, men are more
likely than women to start smoking when they are young, to smoke more
heavily, and to be nicotine dependent. Two separate groupings of countries
appeared to emerge from the between-country comparisons Belarus, Kazakhstan,
Russia, and Ukraine, on one hand, and Armenia, Georgia, Kyrgyzstan, and
Moldova, on the other. In addition to exhibiting higher smoking rates among
women and more pronounced age-specific trends, the former group tended to
show lower ages at smoking initiation (particularly in comparison with
Armenia, Georgia, and Moldova) along with more marked gender differences in
regard to number of cigarettes smoked per day and level of nicotine
dependency.
The differences observed in this study suggest that smoking patterns in
Armenia, Georgia, Moldova, and Kyrgyzstan are more traditional than those in
Belarus, Kazakhstan, Russia, and Ukraine This situation can be explained by
the differing degree of transnational tobacco company penetration.(FN21,44)
Industry in Moldova continues to be in the form of a state-owned monopoly,
industry in Georgia and Armenia has been privatized, but this change was
rather recent (occurring after 1997), and none of the major transnational
tobacco companies invested directly in those countries.(FN21) Kazakhstan,
Russia, and Ukraine, by contrast, saw major investments from most major
transnational tobacco companies beginning in the early 1990s Belarus, which
retains a state-owned monopoly system, and Kyrgyzstan, where the German
cigarette manufacturer Reemtsma has invested would therefore appear to be
exceptions, with Belarus more typical of the countries with transnational
tobacco company investments and Kyrgyzstan more typical of the countries
without such investments. In Belarus, however, the state tobacco
manufacturer has only a 40% market share, with smuggled and counterfeit
brands accounting for an additional 40% of this share. The importance the
transnational tobacco companies attach to the illegal market in Belarus can
be seen in the fact that, despite having little official market share,
(FN44) British American Tobacco and Philip Morris have the highest outdoor
advertising budgets and the 9th and 10th highest television advertising
budgets of all companies operating in that country (FN45) In Belarus, as in
Ukraine and Russia tobacco is the product most heavily advertised outdoors
and the fourth most ad vertised product on television (there are now
restrictions on television advertising in Ukraine and Russia). (FN45,46)
Thus, it appears that with the continuing (if so far fruitless) discussions
of possible reunification with Russia, the transnational tobacco companies
treat Belarus as an important extension of the Russian market.
Kyrgyzstan differs from the other countries in which there have been
transnational tobacco company investments in that these investments occurred
later (in 1998) and one company, Reemtsma, achieved a manufacturing monopoly
(FN44) However, Kyrgyzstan also differs from Belarus, Kazakhstan, Ukraine,
and Russia in regard to its lower levels of development and
industrialization and its larger rural and Muslim populations Other
potential explanations for the between country differences observed cannot
be excluded here, and such possibilities are explored in a separate article
(FN48) Whatever reasons emerge, the rising rates of smoking among women and
the younger ages of smoking initiation are cause for concern in all of these
countries.
Meanwhile, the present findings, combined with earlier data on disease
burden,(FN1,37) confirm that high smoking rates among men continue unabated
Smoking among women in Armenia Georgia, Kyrgyzstan, and Moldova remains
relatively uncommon and does not appear to have increased significantly, as
can be seen in rates among the younger relative to older generations and in
limited comparisons with previous data By contrast, smoking rates among
women in Belarus, Ukraine, Kazakhstan, and Russia showed an increase from
previous surveys, and age-specific rates suggest an ongoing increase in
tobacco use among members of the younger generations It is probably not a
coincidence that these higher rates were observed in the countries with the
most active transnational tobacco company presence.
Conclusions
Concerted and urgent efforts to improve tobacco control must be made
throughout the former Soviet Union to curtail current smoking and prevent
further rises in smoking among women Such efforts will require enactment and
effective enforcement of comprehensive tobacco control policies, including a
total ban on tobacco advertising and sponsor ship adequate taxation of both
imported and domestic cigarettes, controls on smuggling, and restrictions on
smoking in public places The barriers to achieving these goals are
considerable given the powerful influence of transnational tobacco companies
and the limited development of democracy and civil society groups in much of
the region.(FN21) The international community cognizant of the role that
international companies play in pushing the tobacco epidemic should build on
the work of the Open Society Institute (R. Bonnell, oral communication,
September 2003) in strengthening the policy response to this threat.
ADDED MATERIAL
About the Authors
Anna Gilmore Joceline Pomerleau, and Martin McKee are with the European
Centre on Health of Societies in Transition London School of Hygiene and
Tropical Medicine London England Richard Rose is with the Centre for the
Study of Public Policy University of Strathclyde, Glasgow Scotland. At the
time of the study Christian W. Haerpfer was with the Institute for Advanced
Studies Vienna Austria David Rotman is with the Center of Sociological and
Political Studies Belarus State University Minsk Belarus Sergej Tumanov is
with the Centre for Sociological Studies Moscow State University Moscow
Russia.
Requests for reprints should be sent to Anna Gilmore MSc MFPH European
Centre on Health of Societies in Transition London School of Hygiene and
Tropical Medicine Keppel Street London WC1E 7HT, England (e mail:
[email protected]).
This article was accepted December 29 2003.
Contributors
A Gilmore contributed to questionnaire design and data analysis and
drafted the article J. Pomerleau and M. McKee contributed to questionnaire
design data analysis and revisions of the article R. Rose contributed to
questionnaire design and generation of hypotheses C.W. Haerpfer D. Rotman
and S Tumanov designed and supervised the conduct of the surveys. M McKee
C.W. Haerpfer D. Rotman and S. Tumanov originated and supervised the overall
study.
Acknowledgments
We are grateful to the members of the Living Conditions Lifestyles and
Health Study teams who participated in the coordination and organization of
data collection for this study The Living Conditions Lifestyles and Health
Study is funded by the European Community (contract ICA2-2000-10031) Support
for A Gilmore's and M McKee's work on tobacco was also provided by the
National Cancer Institute (grant 1 R01 CA91021 01).
Note The views expressed in this article are those of the authors and do
not necessarily reflect the views of the European Community.
Human Participant Protection
This study was approved by the ethics committee of the London School of
Hygiene and Tropical Medicine Verbal informed consent was obtained from all
study participants at the beginning of the interviews.
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Living Conditions, Lifestyles and Health Study Addiction. In press.
FIGURE 1-Current (a) male and (b) female smoking prevalence rates, by age
group.
The Living Conditions, Lifestyles and Health Study
SOURCE: American Journal of Public Health 94 no12 2177-87 December 2004
Anna Gilmore, MSc, MFPH
Joceline Pomerleau, PhD, MSc
Martin McKee, MD, FRCP
Richard Rose, DPhil, BA
Christian W. Haerpfer, PhD, MSc
David Rotman, PhD
Sergej Tumanov, PhD
ABSTRACT
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. (Am J Public Health.
2004;94:2177-2187)
In 1990, it was estimated that a 35-year-old man in the former Soviet
Union had twice the risk of dying from tobacco-related causes before the age
of 70 years as a man in the European Union (20% vs 10%).(FN1) In the former
Soviet Union, 56% of male cancer deaths and 40% of all deaths are attributed
to tobacco, compared with 47% and 35%, respectively, in the European
Union.(FN1) Rates of circulatory disease among both men and women are
approximately triple those in the European Union.(FN2) Moreover,
tobacco-related mortality continues to increase in the former Soviet Union,
while it has stabilized or declined in the European Union as a whole.(FN1)
Despite these deplorably high levels of tobacco-related mortality,
relatively little is known about smoking prevalence rates in the region.
Virtually no recent or reliable data exist for the central Asian countries
(Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan),(FN2,3)
and recent surveys conducted in Georgia have been limited to the capital,
Tbilisi.(FN4,5) Data from elsewhere in the Caucasus (Armenia, Azerbaijan)
are scarce,(FN6) and historical figures(FN7) are inconsistent with later
findings, leading authors to rely on anecdotal reports of smoking
rates.(FN8).
Historical(FN3) and more recent data, derived largely from Russia,(FN9)
Ukraine,(FN10) Belarus,(FN11) and the Baltic states,(FN12) show-perhaps
unsurprisingly, given the mortality figures just described-that smoking
rates among men are high (45%-60%) while rates are far lower among women
(1%-20%).(FN2) The higher rates previously seen among Estonian women are now
being matched by rates among women in the other Baltic states (FN2,12,13)
and by women in other urban areas.(FN9,10) Unfortunately, other than the
Baltic states, few countries collect information using similar data
collection tools, thereby precluding accurate between-country comparisons.
These issues underlie the need in the former Soviet Union for comparable
and accurate data on smoking prevalence, given that such data are widely
recognized as a prerequisite for the development of effective public health
policies.(FN14-16) This need is made more urgent by the profound changes
occurring as a result of the former Soviet Union's recent economic
transition and, more specifically, by the changes taking place in its
tobacco industry.(FN17) The latter were first felt as soon as these formerly
closed markets opened, with a rapid influx of cigarette imports and
advertising.(FN18-20) Later, as part of the large-scale privatization of
state assets, most of the newly independent states privatized their tobacco
industries, and the transnational tobacco companies established a local
manufacturing presence, investing more than $2.7 billion in 10 countries of
the former Soviet Union between 1991 and 2000.(FN21) Evidence from the
industry's previous entry into Asia suggests that these changes are likely
to have a significant upward impact on cigarette consumption.(FN22,23)
In response to these and other health and social issues facing the
region, a major research project-the Living Conditions, Lifestyles and
Health Study-was commissioned as part of the European Union's Copernicus
program. This investigation involved surveys conducted in 8 of the 15 newly
independent states: Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan,
Moldova, Russia, and Ukraine.(FN24) We present data on smoking prevalence,
including age-and gender-specific smoking rates, age at initiation of
smoking, and indicators of nicotine dependence.
METHODS
Study Population and Sampling Procedures
In autumn 2001, quantitative cross-sectional surveys were conducted in
each country by organizations with expertise in survey research using
standardized methods(FN25) (described in detail elsewhere(FN26)). In brief,
each survey sought to include representative samples of the national adult
population 18 years or older, although a few small regions had to be
excluded as a result of geographic inaccessibility, sociopolitical
situation, or prevailing military action: Abkhazia and Ossetia in Georgia,
the Transdniester region and the municipality of Bender in Moldova, the
Chechen and Ingush republics, and autonomous districts located in the far
north of the Russian Federation.
Samples were selected via multistage random sampling with stratification
by region and area. Within each primary sampling unit, households were
selected according to standardized random route procedures; the exception
was Armenia, where household lists were used to provide a random sample.
Within each household, the adult with the birthday nearest to the date of
the survey was selected to be interviewed. At least 2000 respondents were
included in each country; 4006 residents of the Russian Federation and 2400
residents of Ukraine were interviewed, reflecting the larger and more
diverse populations of these countries.
Questionnaire Design
The first draft of the questionnaire was created, in consultation with
country representatives, from preexisting surveys conducted in other
transition countries(FN9,10,12) and from New Russia Barometer surveys(FN27)
adjusted to national contexts. It was developed in English, translated into
national languages, back-translated to ensure consistency, and pilot tested
in each country. Trained interviewers administered the questionnair in
respondents' homes.
Statistical Analyses
Stata (Version 6; Stata Corp, College Station, Tex) was used to analyze
the data. As a means of reducing the skewness of their distribution, the
continuous variables of age at smoking initiation and smoking duration were
transformed, via log-normal transformations, before analyses were conducted;
however, they were returned to their original units in computing results.
Current smokers were defined as respondents reporting currently smoking
at least 1 cigarette per day. We calculated age-and gender-specific smoking
prevalence rates for each country. Given the negative health effects of
early initiation, we examined age at smoking initiation among current
smokers, as well as number of cigarettes smoked. We assessed level of
nicotine dependence, an indication of smokers' ability or inability to quit,
by identifying the percentage of current smokers who smoked more than 20
cigarettes per day and smoked within an hour of waking. This level of use is
equivalent to a score of 3 or more on the abbreviated Fager-strom dependency
scale(FN28,29) and indicates moderate (score of 3 or 4) to severe (score of
5 or above) dependency.
Within each country, gender differences in smoking habits were assessed
with x[sup2] tests and 2-sample t tests; variations according to age group
were estimated via logistic regression analyses in which the 18-to 29-year
age group was the reference category. Logistic regression analyses with
Russia as the baseline were used in making between-country comparisons in
likelihood of smoking, while analyses of variance combined with Bonferroni
multiple comparison tests were used in comparing geometric mean ages at
smoking initiation. To allow for the large number of comparisons, we used
99% confidence intervals and set the significance level at .01.
RESULTS
Response Rates
A total of 18428 individuals were surveyed. Response rates (calculated
from the total number of households for which an eligible person could be
identified) varied from 71% to 88% among the countries included. Rates of
nonresponse for individual items were very low (e.g., 0.03% for current
smoking and 0.5% for education level).
Sample Characteristics and Representativeness
The samples clearly reflected the diversity of the region and were
broadly representative of their overall populations (Table 1). Comparisons
of the present data and official data are potentially limited by the failure
of some of the country data to fully capture posttransition migration and
other factors,(FN30) but they suggest slight underrepresentations of men in
Armenia and Ukraine, of the urban population in Armenia, and of the rural
population in Kyrgyzstan. Age group comparisons among the respondents 20
years or older suggested a tendency for the oldest age group to be
overrepresented at the expense of the youngest age group, particularly in
Armenia, Moldova, and Ukraine.
Smoking Prevalence
Rates of male smoking were high. In many of the countries surveyed,
almost 80% of male respondents reported a history of smoking (Table 2).
Rates of current smoking were lowest in Moldova (43.3%) and Kyrgyzstan
(51.0%) and highest in Kazakhstan (65.3%), Armenia (61.8%), and Russia
(60.4%). Smoking rates in Russia were not distinguishable from those in
Kazakhstan, Armenia, or Belarus but were significantly higher than those
observed in Moldova, Kyrgyzstan, Ukraine, and Georgia (P<.01; data not
shown).
Rates among women were far lower (gender comparisons were significant at
the .001 level in all countries) and somewhat more variable, ranging from
2.4% to 15.5%; the lowest rates were seen in Armenia, Moldova, and
Kyrgyzstan and the highest in Russia, Belarus, and Ukraine. Smoking among
women in Russia was significantly more prevalent than among women in all of
the other countries under study (P<.01) although adjusting for age removed
the difference between Russia and Belarus (data not shown).
The relationship between smoking and age varied by gender. Among men,
with the exception of those residing in Moldova, smoking prevalence rates
varied little between the ages of 18 and 59 years but then declined more
markedly in men above the age of 60 years (Table 2, Figure 1). This decline
with age was accounted for by increases in the older groups in terms of
percentages of former smolers and never smokers. Among women, the overall
trend was a decrease in reports of both current and former smoking with
increasing age; very low smoking rates were observed in the oldest age group
(rates of reported lifetime smoking varied from 0.8%-3.9%). However, closer
inspection of the data suggested that the countries could be divided into 2
groups. In the first group (Russia, Belarus, Ukraine, and Kazakhstan), rates
of current and ever smoking implied that initiation of smoking had increased
rapidly between generations, especially in the youngest age group (Table 2,
Figure 1). In the second group (Armenia, Georgia, Kyrgyzstan, and Moldova),
the age trends were less obvious and were nonsignificant (with the exception
of the comparison of the oldest and youngest age groups in Moldova).
TABLE 1-Characteristics of Samples and Countries in the Living
Conditions, Lifestyles and Health Study: 8 Countries of the Former Soviet
Union, 2001
Characteristic AR BY GE KZ
KG MD RU UA
Simple
Response rate, % 88 73 88 82
71 81 73 76
Gender
Male, % 40.3 44.1 45.7
44.4 45.0 45.1 43.5 38.8
Men aged [greater or equal] 20 y, 40.7 43.9
45.6 44.1 45.6 44.9 43.2 38.6
No. 2000 2000 2022 2000
2000 2000 4006 2400
Age group, y, %
20-29 15.4 16.9 13.9
21.9 26.7 14.5 16.5 14.6
30-39 21.6 19.2 20.3
25.8 26.0 20.1 19.3 16.4
40-49 24.0 21.6 21.9
21.5 21.4 23.1 20.9 17.9
50-59 11.1 14.5 16.3
12.0 10.1 16.4 15.4 15.5
[greater or equal]60 28.0 27.9
27.6 18.8 15.9 26.0 27.9 35.5
No. aged [greater or equal]20 1940 1922
1975 1890 1899 1945 3828 2324
No. aged 18-19 60 78 47 110
101 55 178 76
Interview location, %
State/regional capital 44.0 33.9 41.4
27.0 27.5 30.4 35.7 31.5
Other city/small town 17.0 34.8 15.6
25.4 13.5 11.6 37.1 36.4
Village 39.0 31.4 43.0
47.6 59.0 58.1 27.3 32.1
No. 2000 2000 2022 1850
2000 2000 4006 2400
Reported nationality, %
Nationality of country[supa] 97.3 80.1 90.2
36.3 68.6 76.7 82.4 77.7
Russian 0.8 12.1 1.3
41.5 18.0 7.7 ... 16.5
Other 1.9 7.8 8.5
22.1 13.5 15.7 17.6 5.8
No. 2000 1979 2021 1979
1997 1980 3967 2371
Education, %
Secondary education or less 49.1 49.4 33.8
35.7 48.3 52.2 43.2 44.2
Secondary vocational or some college 30.4 34.2 32.7
43.5 32.7 32.7 35.7 36.1
College 20.5 16.4 33.6
20.8 19.0 15.2 21.1 19.7
No. 1996 1984 1996 1995
1996 1984 4004 2381
Country data
Midyear population, 2001, thousands 3788 9971 5238 14821
4927 4254 144387 49111
Gross national product per capita, 2001, $ 560 1190 620 1360
280 380 1750 720
Men aged [greater or equal]20 y, 2000, % 47.5 45.4
46.4 46.6 47.9 46.3 45.3 44.8
Urban population, 2001, % 67.3 69.6 56.5
55.9 34.4 41.7 72.9 68.0
Age group, y, % of total [greater or equal] 20
20-29 23.2 19.3 20.6
26.0 30.5 23.1 19.6 19.4
30-39 24.2 20.3 21.1
23.7 24.7 20.3 19.6 19.0
40-49 22.5 21.5 19.5
21.4 19.6 22.7 22.4 19.8
50-59 10.3 12.6 12.7
10.9 9.0 13.6 13.3 14.2
[greater or equal]60 19.7 26.4
26.2 18.0 16.2 20.3 25.1 27.6
Unemployment rate, % [supc] 11.7 2.3 11.1
2.9 3.2 2.0 13.4 5.8
Tobacco industry state owned (SO) P SO P
P P SO P P
or privatized (P)
Foreign direct investment in tobacco 8 0 0
440 ... 0 1719 152.9
industry, end of 2000, $ millions[supd]
Foreign direct investment in tobacco 0.002 0.000 0.000
0.030 ... 0.000 0.012 0.003
industry per capita x 1000[supd]
Note AR=Armenia; BY=Belarus; GE=Georgia; KZ=Kazakhstan; KG=Kyrgyzstan;
MD=Moldova; RU=Russia; UA=Ukraine.
[supa]Mean Armenians in Armenia, Belarussians in Belarus, Georgians in
Georgia, Kazakhs in Kazakhstan, Kirghiz in Kyrgyzstan, Moldovans/Romanians
in Moldova, Russians in Russia, and Ukrainians in Ukraine.
[supb]Data sources were European Health for All Database, January 2003;
Population Division of the Department of Economic and Social Affairs of the
United Nations Secretariat.
[supc]In 1999 for Russia, 2000 for Armenia and Ukraine, and 2001 for the
other countries.
[supd]Data from Gilmore and McKee(FN21); these are minimum investment
figures.
[Table Omitted]
Age at Initiation
The majority of male smokers reported that they began smoking before the
age of 20 years, and, on average, a quarter reported that they began in
childhood (Table 3). Far fewer women reported beginning in childhood, and
sizable percentages began after the age of 20 years; for example, 86% of
women residing in Armenia and more than 40% of women residing in Georgia,
Kyrgyzstan, and Moldova reported that they initiated smoking after this age.
These gender differences were significant in all of the countries under
study.
Differences also were observed between countries; in Belarus,
Kazakhstan, Russia, and Ukraine, geometric mean ages at smoking initiation
were younger than 18 years among men and younger than 20 years among women,
compared with older ages at smoking initiation elsewhere. Overall,
between-country differences were significant for both women and men (P<.
001); however, Bonferroni multiple comparisons showed that there were
significant differences among women only in comparisons involving Armenia
and countries other than Georgia and Moldova (P< 01; data not shown). Among
men, significantly younger ages at initiation were observed in Russia and
Ukraine versus Armenia, Georgia, Kyrgyzstan, and Moldova; in Belarus versus
Armenia and Kyrgyzstan; and in Kazakhstan versus Kyrgyzstan (all P< 01; data
not shown).
Amount Smoked and Nicotine Dependence
Men were found to smoke more cigarettes than women, the majority of men
smoked 10 or more cigarettes per day, while most women smoked fewer than 10
per day.
Between-gender differences in percentages of respondents smoking more
than 20 cigarettes per day were significant only in the case of Belarus,
Kazakhstan, Russia, and Ukraine (P< 001).
The majority of smokers reported smoking their first cigarette within an
hour of waking, although, in all countries other than Georgia, a far higher
proportion of men than women did so (P< 01). Thus, men were more likely to
be moderately to severely dependent on nicotine, although gender differences
were significant only for Belarus, Kazakhstan, Russia, and Ukraine.
DISCUSSION
The surveys conducted in this study provide important new data on the
prevalence of yin in 8 countries representing more than four fifths of the
population of the former Soviet Union. In the case of some of these
countries, these data represent the first accurate, countrywide smoking
prevalence data reported. In addition, they provide some of the first truly
comparative data for countries of the former Soviet Union other than the
Baltic states,(FN31,32) and, because of the focus on obtaining accurate
information on sample characteristics, they offer advantages over data
available in public databases. Response rates were relatively high, and the
samples were broadly representative of the overall country populations.
TABLE 3-Smoking Characteristics of Current Smokers in 8 Countries of the
Former Soviet Union, 2001
AR,% BY,% GE,% KZ,% KG,% MO,%
RU,% UA,% All,[supa]% Between-Country
Compadson, p[supb]
Age at smoking initiation, y
Men
Mean age 18.5 17.4 18.2 17.6 19.1 18.2
17.0 17.2 17.9
Geometric mean age 17.8 16.6 17.7 17.1 18.6 17.6
16.2 16.2 17.2 <.001
<16 22.2 32.8 18.0 27.9 14.7 22.8
36.4 35.2 26.2
16-20 56.8 54.2 66.0 57.0 61.8 59.9
49.8 48.5 56.7 <.001
>20 21.0 13.0 16.0 15.1 23.5 17.3
13.9 16.3 17.0
No 447 430 400 502 408 347
993 435 3962
Women
Mean age 28.0 18.9 22.7 20.7 21.5 23.0
20.9 21.2 22.1 <.001
Geometric mean age 27.0 18.5 21.3 19.9 20.7 21.5
19.8 19.9 21.1
<16 0.0 20.0 18.5 15.4 12.5 22.9
13.1 15.1 14.7 <.001
16-20 14.3 56.7 38.5 50.6 43.8 22.9
52.6 57.2 42.1
>20 85.7 23.3 43.1 34.1 43.8 54.3
34.4 27.6 43.3
No 28 120 65 91 28 35
329 152 868
Between gender comparison <.001 .002 <.001 <.001 .002
<.001 <.001 <.001
in geometric mean age[supc]
Number of cigarettes
smoked daily
Men
1-2 1.8 3.4 1.9 4.5 15.4 8.2
2.4 4.6 5.3
Up to 10 18.7 32.3 12.7 30.9 50.1 43.3
24.6 25.4 29.8 <.001
10-20 51.4 50.5 63.3 48.0 28.7 37.4
52.2 53.5 48.1
>20 28.1 13.7 22.2 16.6 5.8 11.0
20.8 16.5 16.9
Odds ratio for likelihood 1.487 0.606 1.085 0.756 0.234
0.471 1.00 0.753
of smoking >20
cigarettes per day
P .002 .001 .539 .038 <.001
<.001 .049
No 498 495 482 579 449 390
1052 484 4429
Women
1-2 32.1 23.7 11.9 19.4 36.2 37.2
18.7 22.2 25.2
Up to 10 28.6 48.9 29.9 53.4 46.8 41.9
56.6 45.7 44.0 .065
10-20 32.1 25.2 46.3 23.3 17.0 18.6
19.8 26.5 26.1
>20 7.1 2.2 11.9 3.9 0.0 2.3
4.9 5.6 4.7
Odds ratio for likelihood 1.50 0.44 2.64 0.79 ...
0.46 1.00 1.15
of smoking > 20
cigarettes per day
P 0.602 0.199 0.032 0.672 ...
0.461 0.749
No. 28 135 67 103 47 43
348 162 933
Between gender comparison .015 .000 .053 .001 .090
.073 <.001 <.001
of % smoking >20
cigarettes per day[supd]
Time when usually smoke first
cigarette
Men
First 30 minutes 63.5 47.9 52.9 42.8 39.0 44.1
56.5 55.8 50.3
after awakening
First hour 24.9 40.4 34.0 46.6 39.4 38.2
34.3 33.3 36.4 <.001
after awakening
Before midday meal 4.6 6.9 5.0 5.0 7.1 6.7
4.7 6.0 5.7
After midday meal or 7.0 4.9 8.1 5.5 14.5 11.0
4.6 5.0 7.6
in the evening
Odds ratio for likelihood 0.77 0.77 0.67 0.86 0.37
0.47 1.00 0.83
of smoking in first hour
P .140 .129 .021 .394 <.001
<.001 .292
No. 498 495 480 579 449 390
1051 484 4426
Women
First 30 minutes 50.0 31.9 44.6 35.0 27.7 14.3
33.7 27.8 33.1
after awakening
First hour 14.3 28.9 30.8 27.2 31.9 38.1
32.0 32.1 29.4 .278
after awakening
Before midday meal 3.6 19.3 12.3 13.6 12.8 11.9
13.5 17.3 13
After midday meal 32.1 20.0 12.3 24.3 27.7 35.7
20.8 22.8 24.5
or in the evening
Odds ratio for 0.94 0.81 1.60 0.86 0.77
0.57 1.00 0.78
likelihood of smoking
in first hour
P .879 .307 .129 .505 .409
.092 .203
No. 28 135 65 103 47 42
347 162 929
Between gender comparison <.001 <.001 .014 <.001 .004
<.001 <.001 <.001
in % smoking in
first hour[supd]
Moderate to heavy nicotine
dependence (> 20 cigarettes
per day and smoking within
first hour of awakening)
Men 26.9 13.7 21.4 16.6 5.6 10.5
20.6 16.2 16.4 .000
Odds ratio for likelihood 1.42 0.62 1.05 0.77 0.23
0.45 1.00 0.74 0.8
of moderate to severe
dependency
P .005 .093 .142 .104 .000
.000 .042 .00
No. 498 495 477 579 449 390
1051 483 4422
Women 7.1 2.2 10.8 3.9 0.0 1.0
17.0 9.0 6.4 .139
Odds ratio for likelihood 1.49 0.44 2.34 0.78 ...
0.47 1.00 1.14 1.0
of moderate to severe
dependency
P .605 .197 .071 .669 ...
.473 .754 .3
No 28 135 65 103 47 42
347 162 929
Between gender .020 <.001 .045 .001 .097
.091 <.001 .001
dependency comparison[supd]
Note. AR = Armenia; BY = Belarus; GE = Georgia; KZ = Kazakhstan; KG
Kyrgyzstan; MD = Moldova; RU = Russia; UA = Ukraine.
[supa]Average, assuming the same number of respondents in each country.
[supb]Results of analyses of variance (geometric mean) and x[sup2] tests
(categorical variable) for mean age at smoking initiation; x[sup2] test for
no. of cigarettes smoked, time to first cigarette, and dependency.
[supc]Results of tests.
[supd]Results of x[sup2] tests.
Study Limitations
The underrepresentation of men in Armenia and Ukraine should not have
affected the gender-specific rates observed, but, as a result of the
urban/rural differences in the composition of the sample, prevalence rates
in Kyrgyzstan (where urban areas were overrepresented) may have been
overestimated, and prevalence rates in Armenia (where urban areas were
underrepresented) may have been underestimated. However, these discrepancies
were likely to affect only the data relating to female respondents.(FN9-11)
The age group disparities noted were minor but would tend to lead to
underestimates of smoking prevalence.
In addition, the surveys were based on self-reported smoking status;
there was no independent biochemical validation, and thus the smoking rates
observed may have been affected by reporting bias. Although there is concern
on the part of some that self-reports of smoking status may produce
underestimates of smoking levels, studies conducted in Western countries
suggest that this technique is sensitive and specific; they also suggest
that more accurate responses are provided in interviewer-administered
questionnaires than in self-completed questionnaires (FN33) The only study
conducted in the former Soviet Union that has addressed this issue showed
that among individuals claiming to be nonsmokers, 13% (48/368) of women and
17% (12/375) of men in rural northwestern Russia were in fact, according to
blood cotinine levels, likely to be smokers, compared with only 2% of men
and women in Finland (FN34) Given the far lower prevalence of smoking among
women, this had disproportionately large effects on reported rates of
smoking among women. Although our questionnaires were administered by
interviewers in respondents' homes, potentially making it more difficult for
respondents who smoked to deny doing so, we may have underestimated smoking
prevalence rates, particularly in the case of women residing m areas where
smoking re mains culturally unacceptable.
A final shortfall of the present study was the failure to measure
smokeless tobacco use, which is relatively common in parts of the former
Soviet Union, mainly Azerbaijan, Tajikistan, and Turkmenistan. However,
although chewing tobacco is used in some of the southern regions of
Kyrgyzstan, cigarettes are the main form of tobacco used there as well as in
all of the other countries in which surveys were conducted.(FN8,35)
Findings
The results of our study confirm that smoking rates among men in this
region are among the highest in the world and higher than the maximum rates
recorded in the United States at the peak of its epidemic; rates above 50%
were observed in all countries other than Moldova and reached 60% or more in
Armenia, Kazakhstan, and Russia Elsewhere in Europe, rates above 50% are
seen only in Turkey (51%) and Slovakia (56%), and worldwide fewer than 20
countries report rates of more than 60%.(FN6)
In the case of men, the lower prevalence of current smokers and higher
prevalence of never and former smokers among those 60 years or older
probably reflect the disproportionate number of premature deaths among
current smokers relative to never and former smokers However, a cohort
effect has been shown in the former Soviet Union, with those who were
teenagers between 1945 and 1953 carrying forward lower smoking rates because
cigarettes, like other consumer goods, were in short supply in the period of
postwar austerity under Stalin.(FN36,37) This cohort effect is also thought
to account for the unexpected current decline in male lung cancer deaths,
(FN36) which must be set against the overall rise in male tobacco-related
mortality(FN1) and, in particular increases in the already staggeringly high
number of cardiovascular deaths.(FN2)
In comparison with male smoking patterns, smoking among women is far
less common, vanes more between countries, and exhibits a different
age-specific pattern Although rates of lifetime smoking are below 4% among
individuals older than 60 years in all 8 countries, in the 4 countries with
the highest smoking rates among women (Belarus, Kazakhstan, Russia, and
Ukraine), smoking is now significantly more common among members of the
younger generations, risk ratios between the youngest and oldest age groups
range from 12.2 to 37.3, compared with a range to 1.0 to 5.5 in the other 4
countries.
Lopez et al.(FN38) outlined a 4-stage model of the patterns of a smoking
epidemic based on observations from Western countries In this model, such an
epidemic is described as involving an initial rise in male smoking followed
by a rise in female smoking 1 to 2 decades later, after which each plateaus
and then falls as a result of tobacco-related mortality, finally rising to a
peak decades later Our findings suggest that the former Soviet Union's
tobacco epidemic may have developed differently Male smoking has a long
history in this region The first accounts of tobacco smoking in Russia date
from the 17th century, (FN39) papirossi (a type of cigarette, popular in the
former Soviet Union, characterized by a long, hollow mouthpiece that can be
twisted before smoking) were first mentioned in 1844, (FN39) and cigarette
factories were first constructed later in the 19th century. (FN40,41)
Historical data on smoking(FN3) and high male tobacco-related mortality
rates(FN1) suggest that smoking among men has been at a high level for some
time and, contrary to the predictions of the 4-stage model just mentioned,
has failed to exhibit a postpeak decline.
Smoking among women remains relatively uncommon, and rates have been far
slower to rise than would be expected given male rates in the former Soviet
Union and trends observed in the West. Indeed, it appears that female rates
began to increase only in the mid-to late 1990s, when transnational tobacco
companies arrived with their carefully targeted marketing strategies
(FN18-20) Therefore, although the exact stage of the epidemic varies
slightly between the countries of the former Soviet Union, overall we
suggest that men have remained between stages 3 and 4, with high rates of
both smoking and mortality, while women in some countries are at stage 1 and
others at stage 2, the latter with more rapidly rising smoking rates
Although rates of cardiovascular disease have been increasing, this can
largely be explained by risk factors other than tobacco (including diet and
stress), and female lung cancer rates have yet to increase.
Comparisons between our results and previous data are problematic given
that much of the information that exists is fragmentary, of uncertain
quality, and rarely nationally representative This is particularly the case
in the central Asian and Caucasian states, although limited data from
Armenia and Moldova gathered between 1998 and 2001 suggest few changes in
smoking prevalence rates (FN2,6); data from Kazakhstan suggest small
increases from the 60% male and 7% female prevalence rates; recorded in
1996.(FN2) More data are available for Belarus, Russia, and Ukraine These
data suggest that smoking rates m men have changed little, (FN2,10,11,42)
although m Russia they appeared to rise between the 1970s and 1980s(FN2,3,7)
and into the mid-1990s, with little subsequent change Among women, rates
appear to have increased in all 3 countries, (FN2,11) and Russian data
suggest that although rates have been rising since the 1970s, increases were
most notable during the 1990s. (FN3,7,9,43)
Between-gender and intercountry differences in smoking prevalence rates
are relater in other smoking indicators as well; for example, men are more
likely than women to start smoking when they are young, to smoke more
heavily, and to be nicotine dependent. Two separate groupings of countries
appeared to emerge from the between-country comparisons Belarus, Kazakhstan,
Russia, and Ukraine, on one hand, and Armenia, Georgia, Kyrgyzstan, and
Moldova, on the other. In addition to exhibiting higher smoking rates among
women and more pronounced age-specific trends, the former group tended to
show lower ages at smoking initiation (particularly in comparison with
Armenia, Georgia, and Moldova) along with more marked gender differences in
regard to number of cigarettes smoked per day and level of nicotine
dependency.
The differences observed in this study suggest that smoking patterns in
Armenia, Georgia, Moldova, and Kyrgyzstan are more traditional than those in
Belarus, Kazakhstan, Russia, and Ukraine This situation can be explained by
the differing degree of transnational tobacco company penetration.(FN21,44)
Industry in Moldova continues to be in the form of a state-owned monopoly,
industry in Georgia and Armenia has been privatized, but this change was
rather recent (occurring after 1997), and none of the major transnational
tobacco companies invested directly in those countries.(FN21) Kazakhstan,
Russia, and Ukraine, by contrast, saw major investments from most major
transnational tobacco companies beginning in the early 1990s Belarus, which
retains a state-owned monopoly system, and Kyrgyzstan, where the German
cigarette manufacturer Reemtsma has invested would therefore appear to be
exceptions, with Belarus more typical of the countries with transnational
tobacco company investments and Kyrgyzstan more typical of the countries
without such investments. In Belarus, however, the state tobacco
manufacturer has only a 40% market share, with smuggled and counterfeit
brands accounting for an additional 40% of this share. The importance the
transnational tobacco companies attach to the illegal market in Belarus can
be seen in the fact that, despite having little official market share,
(FN44) British American Tobacco and Philip Morris have the highest outdoor
advertising budgets and the 9th and 10th highest television advertising
budgets of all companies operating in that country (FN45) In Belarus, as in
Ukraine and Russia tobacco is the product most heavily advertised outdoors
and the fourth most ad vertised product on television (there are now
restrictions on television advertising in Ukraine and Russia). (FN45,46)
Thus, it appears that with the continuing (if so far fruitless) discussions
of possible reunification with Russia, the transnational tobacco companies
treat Belarus as an important extension of the Russian market.
Kyrgyzstan differs from the other countries in which there have been
transnational tobacco company investments in that these investments occurred
later (in 1998) and one company, Reemtsma, achieved a manufacturing monopoly
(FN44) However, Kyrgyzstan also differs from Belarus, Kazakhstan, Ukraine,
and Russia in regard to its lower levels of development and
industrialization and its larger rural and Muslim populations Other
potential explanations for the between country differences observed cannot
be excluded here, and such possibilities are explored in a separate article
(FN48) Whatever reasons emerge, the rising rates of smoking among women and
the younger ages of smoking initiation are cause for concern in all of these
countries.
Meanwhile, the present findings, combined with earlier data on disease
burden,(FN1,37) confirm that high smoking rates among men continue unabated
Smoking among women in Armenia Georgia, Kyrgyzstan, and Moldova remains
relatively uncommon and does not appear to have increased significantly, as
can be seen in rates among the younger relative to older generations and in
limited comparisons with previous data By contrast, smoking rates among
women in Belarus, Ukraine, Kazakhstan, and Russia showed an increase from
previous surveys, and age-specific rates suggest an ongoing increase in
tobacco use among members of the younger generations It is probably not a
coincidence that these higher rates were observed in the countries with the
most active transnational tobacco company presence.
Conclusions
Concerted and urgent efforts to improve tobacco control must be made
throughout the former Soviet Union to curtail current smoking and prevent
further rises in smoking among women Such efforts will require enactment and
effective enforcement of comprehensive tobacco control policies, including a
total ban on tobacco advertising and sponsor ship adequate taxation of both
imported and domestic cigarettes, controls on smuggling, and restrictions on
smoking in public places The barriers to achieving these goals are
considerable given the powerful influence of transnational tobacco companies
and the limited development of democracy and civil society groups in much of
the region.(FN21) The international community cognizant of the role that
international companies play in pushing the tobacco epidemic should build on
the work of the Open Society Institute (R. Bonnell, oral communication,
September 2003) in strengthening the policy response to this threat.
ADDED MATERIAL
About the Authors
Anna Gilmore Joceline Pomerleau, and Martin McKee are with the European
Centre on Health of Societies in Transition London School of Hygiene and
Tropical Medicine London England Richard Rose is with the Centre for the
Study of Public Policy University of Strathclyde, Glasgow Scotland. At the
time of the study Christian W. Haerpfer was with the Institute for Advanced
Studies Vienna Austria David Rotman is with the Center of Sociological and
Political Studies Belarus State University Minsk Belarus Sergej Tumanov is
with the Centre for Sociological Studies Moscow State University Moscow
Russia.
Requests for reprints should be sent to Anna Gilmore MSc MFPH European
Centre on Health of Societies in Transition London School of Hygiene and
Tropical Medicine Keppel Street London WC1E 7HT, England (e mail:
[email protected]).
This article was accepted December 29 2003.
Contributors
A Gilmore contributed to questionnaire design and data analysis and
drafted the article J. Pomerleau and M. McKee contributed to questionnaire
design data analysis and revisions of the article R. Rose contributed to
questionnaire design and generation of hypotheses C.W. Haerpfer D. Rotman
and S Tumanov designed and supervised the conduct of the surveys. M McKee
C.W. Haerpfer D. Rotman and S. Tumanov originated and supervised the overall
study.
Acknowledgments
We are grateful to the members of the Living Conditions Lifestyles and
Health Study teams who participated in the coordination and organization of
data collection for this study The Living Conditions Lifestyles and Health
Study is funded by the European Community (contract ICA2-2000-10031) Support
for A Gilmore's and M McKee's work on tobacco was also provided by the
National Cancer Institute (grant 1 R01 CA91021 01).
Note The views expressed in this article are those of the authors and do
not necessarily reflect the views of the European Community.
Human Participant Protection
This study was approved by the ethics committee of the London School of
Hygiene and Tropical Medicine Verbal informed consent was obtained from all
study participants at the beginning of the interviews.
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