1.13 International comparisons of prevalence of smoking

Last updated: November 2015
Suggested citation: Greenhalgh, EM, Bayly, M, & Winstanley, MH. 1.13 International comparisons of prevalence of smoking. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2015. Available from http://www.tobaccoinaustralia.org.au/chapter-1-prevalence/1-13-international-comparisons-of-prevalence-of-sm

An estimated 1.25 billion adults worldwide are smokers,1 and international findings that 20% of young teenage school students are also current tobacco users (in one form or another) confirm that tobacco-caused illness and death will continue for many decades to come.2,3

1.13.1 International comparisons of adult smoking prevalence

In general, the prevalence of smoking is declining in industrialised countries in Northern and Western Europe, North America and the Western Pacific region, and on the increase in some countries in Asia, South America and Africa.1 As global patterns in tobacco use change, the burden of death can be expected to shift dramatically from the developed world to less wealthy countries. It has been estimated that over the next two decades, 70% of tobacco deaths will be in developing countries.4 About 80% of the world's smokers now live in low and middle income countries, at least in part due to a lack of adequate tobacco controls.5

A paradigm illustrating the typical progression of tobacco use worldwide, first proposed by Lopez and colleagues6 and later adapted by the WHO,7 is reproduced in Figure 1.13.1. Many (but not all) countries' experiences of patterns of tobacco use fit this model.

Figure 1.13.1
Four stages of the tobacco epidemic

Source: Lopez et al12 (Reproduced with permission from BMJ Group).

Stage I of the model is marked by a low smoking prevalence (below 20%), generally limited to males and accompanied by little evident increase in tobacco-caused chronic illness. Countries at stage I have not yet become major consumers in the global tobacco economy, but represent untapped potential for the tobacco industry. Some countries in sub-Saharan Africa fit into this stage in the model.7 The importance of tobacco farming in some countries in the region (e.g. Zimbabwe and Malawi) may act as a deterrent to the introduction of tobacco control policies. Zimbabwe is among the largest producers of tobacco in the world and is a major exporter; concerns about the health consequences of tobacco use are not high on the national agenda.8

In stage II of the paradigm, male prevalence of smoking has soared to more than 50% in men, and women's smoking rates are now increasing. Uptake of smoking is occurring at an earlier age, and, although there is now evidence of increased lung cancer and other chronic illness due to smoking among men, public and political understanding of and support for tobacco control initiatives is still not widespread. Countries that fit into this transitional stage include Japan, some nations within the Southeast Asian, Latin American and North African regions, and to a lesser extent, China. (The case of China is discussed further below).7

Stage III of the epidemic has been reached when smoking prevalence peaks and begins to decline in both sexes, although deaths caused by smoking continue to increase because of earlier high smoking rates. Health education programs are better developed, and smoking becomes less accepted among the more educated groups of society. Smoking becomes less socially acceptable and the climate is increasingly conducive to the introduction of tobacco control policies. Certain countries within Eastern and Southern Europe and Latin America are at this point on the continuum.7

Evolution into stage IV is marked by a continued distinct but gradual downturn in smoking prevalence among both males and females. Male deaths from smoking begin to decline, but female death rates continue to rise, reflecting earlier smoking patterns. Parts of Western Europe, the UK, the US, Canada, New Zealand and Australia are at various points on the continuum in the fourth stage of the tobacco epidemic.6 However, comprehensive and continually monitored public health strategies remain critical to maintain and reinforce declines in smoking prevalence.7

As noted above, there are some countries for which the paradigm devised by Lopez and colleagues in Figure 1.3.1 does not fit. This is especially so in nations in which female smoking rates have not shown a pattern of steady increase in stage II, despite high prevalence among males, most likely due to social or cultural constraints. For example, men in China and Indonesia have maintained high rates of smoking for many years, while female prevalence has remained in single digits. Nevertheless the WHO model described above does provide a useful framework into which many countries can be placed, and may enable countries currently at an earlier stage in the paradigm to recognise their situation, learn from international experience and introduce strong public health measures that will reduce the impact of tobacco on their population. Singapore provides a successful example of early intervention. In the early 1970s, while at stage II of the model, the Singaporean government initiated a series of tobacco control measures which capped smoking prevalence at a relatively low level, effectively averting the later stages of the epidemic. Thousands of tobacco-caused deaths in Singapore have been prevented as a result of this early, decisive action.6

Tables 1.13.1 and 1.13.2 present statistics on smoking prevalence from a number of different countries.

Figure 1.13.2 and Figure 1.13.3 show prevalence data collected by the Organisation for Economic Co-operation and Development (OECD) of its member countries,9 and the data on prevalence on less developed countries in Table 1.13.1 are taken from a wide variety of sources compiled for The Tobacco Atlas (Third Edition) published by the American Cancer Society and World Lung Foundation.10 These tables are provided in order to give a general global overview. It is important to note that data sets between countries are not directly comparable, due to differences in sampling (most crucially the year of the survey) and definitions (daily, regular (daily plus weekly) or current (daily, weekly or less than weekly) smokers), and that overall prevalence figures such as those provided by the tables may mask higher smoking levels among particular sub-groups of the population (most notably men in comparison to women). Further, studies which only take into account the smoking of manufactured cigarettes will underestimate tobacco use in countries where tobacco is widely used in other forms, such as in pipes, hand-rolled leaves or as chewing tobacco. This is a key consideration in countries where alternative methods of tobacco use are prevalent, such as in Sweden11 and throughout much of Southern and Southeast Asia.12,13 The interested reader is referred in the first instance to the primary sources, which explain the parameters of each study.

The global impact of death and disease caused by tobacco smoking is discussed in Chapter 3, Section 3.36.

Figure 1.13.2

Figure 1.13.2
Prevalence of daily smoking among population aged 15+ in OECD countries, males and females*

* Percentages are rounded and appear to have been adjusted to take into account the differing age structures of populations in each country. For the year of data collection, see Figure 1.13.3.
Note: Prevalence figures for Australia differ from those reported in the National Drug Strategy Household Surveys (NDSHS), which are based on the population 14 (rather than 15) and over. They also differ from the figures shown in Table 1.3.2 which has recalculated NDSHS prevalence estimates for the population aged 18+, defining current smoking as at least weekly use of tobacco
Source: OECD Health9

Figure 1.13.3

Figure 1.13.3
Prevalence of daily smoking among population aged 15+ in OECD countries

* Percentages are rounded and appear to have been adjusted to take into account the differing age structures of populations in each country
† Note: Prevalence figures for Australia differ from those reported in the National Drug Strategy Household Surveys (NDSHS), which are based on the population 14 (rather than 15) and over. They also differ from the figures shown in Table 1.3.2 which has recalculated NDSHS prevalence estimates for the population aged 18+, defining current smoking as at least weekly use of tobacco
Source: OECD Health9

Table 1.13.1
Prevalence of tobacco use among adults in selected other countries—males and females, age-standardised

Country

Males %

Females %

Albania

38

4

Bangladesh

44

2

Cambodia

42

4

Chile

32

26

China

45

2

Cook Islands

41

29

Ethiopia

8

1

Fiji

23

5

Gambia

25

<1

India

23

3

Indonesia

57

4

Islamic Republic of Iran

23

2

Israel

26

14

Jordan

43

9

Kazakhstan

43

6

Kenya

20

1

Malaysia

38

1

Mauritius

34

3

Myanmar

31

7

Namibia

25

10

Nauru

52

56

Nigeria

7

1

Papua New Guinea

51

22

Philippines

40

8

Russian Federation

51

17

Samoa

34

13

Singapore

23

4

South Africa

22

9

Sri Lanka

24

1

Thailand

37

2

Ukraine

46

12

United Arab Emirates

18

3

Tanzania

20

2

Vanuatu

29

3

Vietnam

41

2

Zimbabwe

25

3

* Year of study reported, and definition of 'adult' and 'smoker' varies between countries. For further information, refer to primary sources cited by The Tobacco Atlas, which provides prevalence for over 190 countries.

Percentages are rounded
Source: The Tobacco Atlas (Third Edition).10

1.13.2 International comparisons of smoking prevalence in children

The Global Youth Tobacco Survey (GYTS) is a joint project of WHO, the US Centers for Disease Control and Prevention, the Canadian Public Health Association and most WHO member states. The GYTS is a schools-based survey of teenagers aged 13–15, which has enabled consistent data collection from 395 sites encompassing 131 countries, plus the Gaza Strip and the West Bank.2 Table 1.13.2 summarises some of the available data by WHO region, for the years 2007–2014.

Table 1.13.2
Current use of any tobacco product* among school students aged 13‒15 by sex and World Health Organization region, 2007–14^

Region

Boys (%)

Girls (%)

African region^

14

5

Americas region

17

14

Eastern Mediterranean region

21

10

European region^

21

17

Southeast Asian region

21

7

Western Pacific region

12

4

Total

18

8

* ‘Current use’ is defined as any use during the past 30 days. Any tobacco product includes cigarettes, chewing tobacco, snuff, dipping tobacco, cigars, cigarillos, little cigars, pipes, bidis, waterpipes or betel nut combined with tobacco.

Percentages are rounded
^ Updated data for Africa and Europe not available as at October 2015: figures represent 2000–07
Source: Warren et al, 20082 and WHO.14

National data have also been reported for New Zealand, Canada, Ireland, England and the US. These data are of interest since these countries have adopted, to a greater or lesser extent, tobacco control measures which are similar to those operating in Australia. Key findings from some international surveys are reported briefly here and interested readers should refer to the primary sources for further information. Due to methodological differences, it should be noted that these data are not directly comparable with Australian data or with each other.

Results from the most recent New Zealand showed that the current smoking rate in youth (those aged 15–17 years) halved between 2006–07 and 2013–14, falling from 16% to 8%.15 The latest Canadian Youth Smoking Survey (YSS) found that in 2012–13, about 2% of students in grades 6–9 and about 8% of students in grades 10–12 were current smokers. There was an overall decline in smoking prevalence among students in grades 6 to 12 compared to 2010-2011.16 Ireland’s Health Behaviour in School-aged Children Survey 2006 reported that 15% of 10‒17 year olds were current smokers.17 A 2014 survey of health behaviours among 15 year-olds across England found that 8 per cent were current smokers.18

The Monitoring the Future Study from the US reported that in 2014, cigarette smoking reached historical lows among high school students; 1.4% of 8th graders, 3.2% of 10th graders, and 6.7% of 12th graders reported being daily smokers. Compared with 2013, there were statistically significant declines among those in years 10 and 12.19    

1.13.3 Socio-economic status: international comparisons

As discussed in Section 1.13.1, the timing, duration and magnitude of the smoking epidemic has varied significantly from one country to another.23 While westernised countries such as the US, Australia and Canada have been through all four stages of the epidemic and are now experiencing declining prevalence rates and boast sophisticated tobacco control measures, countries in regions such as Southeast Asia and North Africa are currently in the second stage, with high rates of male smoking and lower (but increasing) levels of female smoking.12 The different stages of the tobacco epidemic also vary in terms of socio-economic inequality and smoking.

For example, countries currently at stage II of the epidemic are characterised by little difference between socio-economic groups, if not higher smoking among upper classes,12 while the opposite is true in countries such as Australia, where smoking is higher among lower socio-economic status (SES) groups and lower among higher SES groups and vice versa.

Smoking prevalence data from 19 European countries between 1998 and 200424 indicate that the interaction between socio-economic status and smoking varied quite widely between Northern and Southern Europe, especially among women. This study found that different regions of Europe were experiencing different stages of the tobacco epidemic, likely to be due to variance in socio-cultural processes related to gender empowerment occurring across Europe.

A study examining the association between SES and smoking among immigrants to the US found that being foreign-born or a second generation immigrant had a protective effect against smoking across all SES groups, but most markedly among those in the lowest SES group.25 The authors speculated that differences in the smoking epidemic between country of origin and the US might help explain such a pattern among US immigrants, with those countries in stage II of the epidemic (as described above) likely to have similar smoking rates among different socio-economic classes. A systematic review in 2015 explored the role of acculturation in smoking in immigrants from non-western to western countries. Among less acculturated immigrants, prevalence reflected their countries of origin (i.e., was very high in men and very low in women) and thus the early stage of the epidemic. For those who were more acculturated, prevalence indicated an adaption toward the social norm of the western country (i.e, became higher in women and lower in men) and reflected a more advanced phase of the epidemic.23

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