Smoking in the third world

28 World Health • 48th Yeor, No. 4, July-August 1995 Smoking in the Third World Sherif Omar Children who smoke daily are 13 times more likely to use heroin than children who smoke less often; an estimated 3000 children become dependent on tobacco every single day. Ten years ago, WHO warned that smoking diseases will appear in developing countries before communicable diseases and mal- nutrition have been controlled, thus further widening the gap between rich and poor countries. The Director of the Pan American Health Organization (PAHO) said that tobacco is likely to become Latin America 's 21 st century plague and that, unless action is taken now, from the year 2000 tens of thousands of Latin Americans will die each year prematurely from tobacco-caused diseases. In the least developed countries, where life expectancy is only 45 to 50 years, chronic diseases like lung cancer and heart disease are gener- ally uncommon because relatively few people survive to those ages when such diseases become mani- fest. In most developing countries, health data and figures showing the patterns of tobacco use are poor and unreliable. Yet smoking is particu- larly risky in poor countries where populations are anaemic because it reduces their blood's oxygen- carrying ability. Very poor people often use tobacco as an appetite suppressant- a cheap and accessible means of warding off hunger pangs. Unfortunately more and more children start using cigarettes. Few governments in the Third World are keen on making decisions that might deny such people the small consolation obtained from smoking or chewing modest amounts of tobacco. Moreover, tobacco is not just a health issue, it has consider- able economic force with social overtones. The area of land under tobacco cultivation throughout the world was 4109 hectares in 1985, 73% of it in developing countries. Tobacco occupies three hectares in every thousand of the world 's arable land, and the total profits on this crop per hectare are normally five times that of maize, and three to four times that of cotton or peanuts. Some impor- tant questions arise: How can alter- native crops be encouraged? Why is the tobacco industry so favoured? What would happen if funds cur- rently used for tobacco cultivation were transferred to other crops? The answers lie in the power of the transnational tobacco companies and their massive financial influence. World Health • 48th Year, No. 4, July August 1995 Anti-smoking messages Campaigns against smoking require a huge financial commitment if they are to spread health education mes- sages to hundreds of millions of people living in populous countries like Brazil, China and Indonesia. Immense barriers stand in the way of widespread dissemi- nation of health education against tobacco in the least developed countries, with their high rate of illiteracy and relatively poor outreach of television and newspapers. Doctors are often in powerful positions to influence both patients and government policy, and this poten- tial has been acknowledged by WHO and nongovernmental orga- nizations like the International Union against Cancer (UICC). But in developing countries, this is not the case and, indeed, medical profession- als are among the groups who smoke most. In developed countries, the to- bacco burden is estimated at 16% of all cancer cases every year, while in developing countries it is 10%. In total, of the 676 000 cases of lung cancer in men, 85% are attributable to smoking. Where males have smoked for several decades, 30-40% of all men 's cancers are attributable to tobacco. Unless control efforts are strengthened in the developing coun- tries, the enormous rise in cigarette consumption will produce a compa- rable rise in cancer in those countries within the next 20 to 30 years. In the Middle East, some 50% of the population are below the age of 20, and they are the target of tobacco propaganda seeking to motivate them to start and continue as regular smokers. Smoking behaviour started centuries ago but as a social habit it is still gaining ground; around 40% of the males above the age of 12 are regular daily smokers, although smoking among women is still low. In certain countries about 25% of the daily smokers use the hookah or hubble-bubble. Although there have been some moves to condemn smoking on Islamic religious grounds, legislation against smoking is not seriously implemented in most countries even though the tobacco business often violates the law, especially as Sachets of "pan masala", a mixture of waste tobacco leaves and floor sweepings from cigarette factories , are sold cheaply in India and prove particularly attractive to children. regards sales promotion and adver- tisement. An early WHO report drew attention to the threat to the Third World from multinational tobacco companies seeking new markets. A later report concluded that the threat had become a reality. The new concept that smoking induces nicotine dependence means that this is consid- ered an addictive drug. This fact is gaining support from international scientific agen- cies. Many stud- ies, including some which have been concealed by the tobacco indus- try, show that nicotine does produce chemical reactions in the body similar to those produced by heroin or cocaine. The relapse rates 29 persons trying to quit using nicotine, alcohol , cocaine and heroin are roughly the same; many even report that it is harder to quit tobacco than various illegal drugs. A new study by the Center on Addiction and Substance Abuse at Columbia University in the USA confirms that nicotine is a "gate- way drug" which is associated with the use of illicit sub- stances. About 65% of cocaine users in the USA have smoked cigarettes. Adults who started to smoke before the age of 15 are three times as likely to be regular hard drug users and more than twice as likely to be regular cocaine users than those who started smoking at 18 or older. Children who smoke daily are 13 times more likely to use heroin than children who smoke less often. Anti-smoking policies must be identified as part of every health strategy in the least developed countries. Health education, public information and smoking cessation programmes must work hand in hand with the legal regulation of tobacco production and sales and the banning of advertisements. • Professor Sherif Omar is Professor of Surgical Oncology at Cairo University. His address is I I Boulos Hanna Street, Dokki, Cairo, Egypt. of dependent The tobacco habit has reached every part of the world