Smoking in the third world / by Uma Ram Nath

Smoking in lhe Third World by Uma Ram Nath The cycle of tobacco use, disease, debate and public action that is already fam- iliar in developed countries of the world is only just starting up in the Third World. In- deed , the developing countries today are poised dangerously between the first and second phases . Growing numbers of people are smoking and there is a discernible increase in smok- ing-related diseases. But we cannot wait for public debate to initiate action; governments must recognise the danger now and act to prevent the spread of the cigarette. There are, of course, many ways of using tobacco apart from the cigarette . Charutos are favoured by South Americans ; the goza or hookah is popular in the Middle East and is also common in South-West Asia; some people chew tobacco or, in India and Pakistan, the betel leaf, or paan . Re- search into the health implications of these habits has not yet delved as deep as the investigation of the cigarette in relation to lung cancer. In any case, skilful and aggressive marketing is now promoting the cigarette in the developing world. The traditional uses of tobacco are being replaced by the cigarette which is less 6 cumbersome than the hookah, for ex- ample . Cigarettes can generally be bought one at a time and not neces- sarily in a packet of ten or twenty and , of course, to the common man they are being promoted as a symbol of sophistication. The booming production of ciga- rettes (measured in billions) in some developing countries indicates the growth of the problem: 1979 1983 - - Kenya . . 4.6 5.3 Algeria 14.0 17.5 Egypt .. 29 .2 44.0 China .. 651.0 962.6 Indonesia . 69 .8 92.1 Cuba .... 28.0 30.0 In the industrialised nations there are fewer smokers than there used to be . But disturbing statistics from Afri- ca cited by Nigerian expert Dr Femi- Pearse show that 31 per cent of uni- versity students in Uganda smoke ; 51 per cent of people between 30 and 54 in one village of Ghana smoke; and 41 per cent of men aged over 20 in Lagos have the habit. Dr Femi-Pearse also points to the substantial numbers of children in secondary or middle schools who smoke: in Lagos- 17 per cent of boys , 2 per cent of girls; in Accra-boys 10 per cent, girls 8 per ~ 0 I s 0 0 .J;: Q_ cent ; in Lusaka- boys 40 per cent , girls 4 per cent. Twenty years from now these young people will begin to fall victim to tobacco-caused sickness. It is time now to prevent that happening. A report presented to WHO's Execu- tive Board last November condemned cigarette smoking as the major avoid- able cause of ill health and early death in the countries where the habit is widespread . It said that 90 per cent of all lung cancer , 75 per cent of chronic bronchitis and emphysema, and a quar- ter of ischaemic heart disease cases in men aged under 65 could be attributed to smoking. While in the developed countries the number of smokers is declining , and the habit is fast becom- ing socially less acceptable, in de- veloping countries it is on the increase "fuelled mainly by intensive and ruth- less promotional campaigns on the part of the transnational tobacco com- panies" . Those companies' activities are not subject to the legislative or advertising controls that generally ex- ist in the developed world , the WHO report said, and it warned that smok- ing diseases will appear in develop- ing countries before communicable diseases and malnutrition have been controlled. This is the urgent need today. While indigenous uses of tobacco may cloud W oRLD HEALTH, June 1986 the assessment of tobacco-related diseases , we can already see clear indi- cations of cigarette-related illness in developing countries. WHO believes tqat an epidemic of lung cancer can be expected as a result of the rapidly increasing cigarette consumption in many developing countries . For in- stance, in India, total cigarette con- sumption rose 400 per cent between 1970 and 1980, in Papua New Guinea it trebled between 1960 and 1980, and in Brazil about 135,000 million cigarettes were smoked in 1981 while cigarette-related diseases far out- stripped the infectious diseases as the leading cause of death . While cigarette manufacturers are endeavouring to sell the low tar cigarette in an attempt to make their product appear "safe" to " Western " consumers , their products bearing in- ternational brand names, but sold in the developing world, have much higher yields of tar and nicotine. A comparison of cigarettes in the Philip- pines and in the United States showed that the former had 50 per cent higher tar content than the latter and some- times twice as much nicotine as the American version. Another assess- ment of cigarettes from Australia and Singapore showed similar results. Cigarettes sold in China, India and Pakistan have a high tar and nic- otine content. Cigars and pipes are dangerous too As few as four cigars or four pipefuls of tobacco give the smoker as much toxic sub- stance as ten cigarettes . Doc- tors at Minnesota University's School of Public Health, in the USA. advised that even people who have never smoked ciga- rettes, only a pipe or cigars, should avoid those too. What can be done to limit the rise of smoking-related diseases in the Third World? One starting point could be to restrict the sphere of influence of the tobacco industry, for whom advertis- ing and promotion of cigarettes are the most powerful weapons. As long as W ORLD HEALTH, June 1986 the cigarette is associated with glamour, it will draw more and more people to it. Some developing coun- tries have been able to legislate on advertising of cigarettes. Malaysia , for instance , has banned all television and radio publicity for cigarettes, although it is still legal for newspapers to carry advertisements. There are a number of special fac- tors to consider in preparing a smok- ing-control package for developing countries. In a population with a low level of literacy, what sort of health warning should be given? What would be the use of such a warning if the indigenous products , such as tobacco for chewing or the bidi (a small hand- rolled cigarette) , carried no caveat? Restrictions on the promotion of cigarettes may be effective but what about the quality of the cigarettes sold? Third World governments need to fix upper limits to harmful sub- stances in cigarettes. The Fifth World Conference on Smoking and Health recommended in 1983 that "the pro- duction and export of cigarettes with a tar yield of more than 20 milligrams should cease worldwide," and that all cigarettes and tobacco products should carry a health warning and precise labelling of tar , nicotine and carbon monoxide content. A potter works with both hands and still draws on his hookah. Photo W HO/Zafar Tobacco is a lucrative export crop for some developing countries and some international agencies give de- velopment aid for the crop. Govern- ments earn money from tobacco tax- ation. Fewer cigarettes sold will mean less revenue. In India, changes to the excise tax structure resulted in the flooding of the market by new and competing brands. As the more expensive ciga- rettes fell within a higher tax bracket, their sales dropped. Challengers to the main producers are now offering cheaper cigarettes and in a plethora of brands. And the Indian smoker has taken these up . In the long run the consequences of sickness and disease , of work days lost and the drain on resources , will be far greater than the short-term gains of tobacco-generated income. Develop- ing countries still have a chance to prevent the growth of smoking. They can ensure that promoting non-smok- ing forms an integral part of an overall primary health care strategy. They can draw up widespread and well-formu- lated education programmes to sup- port the health message. And they can bring in legislation to curb the promo- tion of tobacco. Non-governmental and voluntary organizations will be valuable allies in this battle. In par- ticular the consumer movements that are emerging in developing countries can form the core of an anti-smok- ing network in support of popular initiatives for change. • 7