Regional Situation Analysis of Women and Tobacco in South-East Asia

Transcription

1 Regional Situation Analysis of Women and Tobacco in South-East Asia Conducted for World Health Organization Regional Office for South-East Asia By: Dr. Nyo Nyo Kyaing

2 Contents ACKNOWLEDGEMENTS CONDUCTING THE STUDY EXECUTIVE SUMMARY i ii iv INTRODUCTION 1 PART ONE: BASIC INFORMATION Demography 5 Health Status Indicators 7 Development Indicators 9 Literacy and Education 12 PART TWO: PREVALENCE OF TOBACCO USE AMONG FEMALES IN SOUTH-EAST ASIA REGION 14 Types of tobacco products used in South-East Asia Region 14 (A) Main commercial smoking products 14 (B) Main smokeless tobacco products 15 Bangladesh 16 Prevalence of tobacco use among females in Bangladesh 16 Types of tobacco products used in Bangladesh 19 Trends of annual consumption of cigarettes in Bangladesh 20 Expenditure for tobacco by Bangladeshi women 21 Bhutan 23 Prevalence of tobacco use among females in Bhutan 23 Types of tobacco products used in Bhutan 23 Democratic People s Republic of Korea 24 Consumption of manufactured cigarettes 24 India 25 Prevalence of tobacco use among females in India 25 Types of tobacco products used in India 27 Prevalence of tobacco use among female youth in India 27 Trend of annual consumption of manufactured tobacco products in India 28 Indonesia 29 Prevalence of tobacco use among females in Indonesia 29 Prevalence of tobacco use among female youth in Indonesia 32 Types of tobacco products used in Indonesia 32 Trend of tobacco products consumption in Indonesia 33

3 Maldives 34 Prevalence of tobacco use among females in Maldives 34 Types of tobacco products used in Maldives 34 Annual consumption of tobacco products in Maldives 36 Myanmar 37 Prevalence of tobacco use among females in Myanmar 37 Prevalence of smoking among female youth in Myanmar 40 Types of tobacco products used in Myanmar 40 Annual consumption of tobacco products in Myanmar 43 Nepal 44 Prevalence of tobacco use among females in Nepal 44 Prevalence of smoking among female youth in Nepal 46 Types of tobacco products used in Nepal 46 Annual consumption of tobacco products in Nepal 47 Sri Lanka 48 Prevalence of tobacco use among females in Sri Lanka 48 Prevalence of tobacco use among female youth in Sri Lanka 50 Types of tobacco products used in Sri Lanka 50 Annual consumption of tobacco products in Sri Lanka 51 Thailand 52 Prevalence of tobacco use among females in Thailand 52 Prevalence of smoking among Thai Youth 54 Types of tobacco products used in Thailand 54 Annual consumption of manufactured cigarettes in Thailand 55 PART THREE: HEALTH CONSEQUENCES OF TOBACCO USE 58 Health risks for women who smoke 58 Cancers Cardio-vascular diseases 59 Reproductive Health 59 Others 60 Health Consequences for women who are exposed to ETS 60 Health risks for women who use smokeless tobacco 60 Burden of diseases attributable to smoking 61 Burden of diseases attributable to smoking in South-East Asia Region 62 BANGLADESH 67 Morbidity from Tobacco Use in Bangladesh 67 Morbidity due to Second-hand Smoking in Bangladesh 67 Mortality from Tobacco Use in Bangladesh 68 BHUTAN 69 Morbidity and Mortality from Tobacco Use in Bhutan 69 Democratic People s Republic of Korea 70 Morbidity and Mortality from Tobacco Use in DPR Korea 70

4 INDIA 71 Morbidity due to smokeless tobacco use in India 71 Morbidity due to smoking in India 71 Morbidity due to exposure to ETS in India 72 Mortality from tobacco use in India 73 INDONESIA 76 Morbidity from tobacco use in Indonesia 76 Morbidity from exposure to ETS in Indonesia 80 Mortality from tobacco use in Indonesia 82 Maldives 84 Morbidity from tobacco use in Maldives 84 Mortality due to tobacco use in Maldives 85 Myanmar 86 Morbidity due to tobacco use in Myanmar 86 Studies on health consequences of tobacco in Myanmar. 90 Morbidity due to ETS in Myanmar 91 Mortality due to tobacco use in Myanmar 91 NepaL 93 Morbidity due to tobacco use in Nepal 93 Morbidity due to Exposure to Environmental Tobacco Smoke in Nepal 93 Mortality due to tobacco use in Nepal 93 Sri Lanka 96 Morbidity due to tobacco use in Sri-Lanka 96 Morbidity due to exposure to ETS in Sri-Lanka 96 Mortality due to tobacco use 96 Thailand 98 Mortality from tobacco use in Thailand 98 PART FOUR: WOMEN IN THE TOBACCO EMPLOYMENT 105 Women in the tobacco employment 105 Occupational hazards of tobacco employment in South-East Asia Region. 106 PART FIVE: CAMPAIGNING AGAINST TOBACCO 109 PART SIX : CONCLUSIONS AND RECOMMENDATIONS 114 ANNEX: 120

5 TABLES Table 1.1 Demographic Indicators of South-East Asia Region... 6 Table 1. 2 Female adult population 15 years and above (millions).. 7 Table 1. 3 Health Status Indicators in South-East Asia Region 8 Table 1.4 Infant, Maternal and Under Five Mortality Rates in South-East Asia Region. 9 Table 1.5 Components and calculation of Human Development Indicators of South-East Asia Region, Table 1.6 Percentage or population living in poverty in selected countries of the South-East Asia Region Table 1.7 Human Poverty Index (HPI-1) in selected countries of South-East Asia Region, Table 1.8 Gross primary and secondary enrolment ratios in selected countries of the South-East Asia Region, Table 2.1 Prevalence of tobacco use among females in Bangladesh.. 16 Table2.2 Estimated female population by age and smoking rates, Bangladesh, Table 2.3 Age-sex specific female prevalence of smoking (%) by age group and region (Current smokers), Bangladesh, Table 2.4 Female prevalence of smoking (%) by education group and region (Current smokers), Bangladesh, Table 2.5 Prevalence of tobacco use (%) among females for different types of tobacco products by region (Current users), Bangladesh, Table 2.6 Trend of Annual Consumption of Cigarettes and Bidis, Bangladesh, ( ).. 21 Table 2.7 Average Daily Expenditure on Tobacco by females, Bangladesh, Table 2.8 Average Daily Expenditure for Tobacco by females, Bangladesh, Table 2.10 Prevalence of tobacco use among females, India ( to ). 25 Table 2.11 Prevalence of tobacco use among females (from different sources) India, ( to 2001).. 27 Table 2.12 Tobacco use among female school-going children aged years, India. 28

6 Table 2.13 Trend of Annual Consumption of Cigarettes and Bidis, India ( ). 28 Table 2.14 Prevalence of female smoking by age group, Indonesia ( ). 30 Table 2.15 Tobacco use prevalence (smoking and smokeless) among females by age group, Indonesia (1993 to 1998).. 31 Table 2.16 Selected Prevalence Surveys on smoking in Indonesia Table 2.17 Youth female Smoking in Indonesia, ( ). 32 Table 2.18 Prevalence of tobacco use for population 15 years and above, by sex and tobacco product, Indonesia, Table 2.19 The average number of cigarettes consumed by female smokers, (in pieces annually), Indonesia, Table 2.20 Annual Consumption of manufactured cigarettes, Indonesia ( ). 34 Table 2.21 Prevalence of female smoking by age group, Maldives (1997, 2001) 34 Table 2.22 Prevalence of female smoking by age group, Maldives ( 2001). 35 Table 2.23 Annual Consumption of manufactured cigarettes 36 Table 2.24 Prevalence of tobacco use among females > 15 years, Myanmar, Table 2.25 Prevalence rates of smoking among females from specific studies conducted in Myanmar 38 Table 2.26 Prevalence rates of smoking among females for specific groups from studies conducted in Myanmar. 38 Table 2.27 Age-sex specific prevalence of current smoking among females in Myanmar, Table Types of tobacco used in Myanmar, Table Percentage distribution of types of tobacco used within sex groups, Myanmar, Table 2.30 Annual Consumption of manufactured cigarettes.. 43 Table 2.31 Female smoking prevalence in Nepal (1980 to 2001). 44 Table 2.32 Smoking prevalence rate for female population 10 years of age and over by ecological region and literacy, Nepal, Table 2.33 Number of cigarettes/bidi smoked during most recent pregnancy by literacy, Nepal, Table 2.34 Youth female smoking in Nepal, ( ) 46

7 Table 2.35 Cigarette and bidi smoking rates (%) for population 15 years of age and over and estimates of per capita consumption of cigarettes and bidi, Nepal, Table 2.36 Trend of Annual Consumption of Cigarettes and Bidis in Nepal Table 2.37 Prevalence of tobacco use among females in Sri Lanka. 49 Table 2.38 Youth female smoking, Sri Lanka, Table 2.39 Trend of Annual Consumption of manufactured cigarettes in Sri Lanka 51 Table 2.40 Female Smoking prevalence in Thailand, 1976 to Table 2.41 Estimated smoking prevalence trends by sex and population aged 15 or more and males intensity of smoking compared to females in Thailand, Table 2.42 Smoking prevalence by urban/rural division, sex and smoking habit, Thailand, Table 2.43 Smoking prevalence among Thai women by Region, Table 2.44 Prevalence of Youth smoking, Table 2.45 Types of tobacco products used in Thailand by Region, Table 2.46 Types of tobacco products used in Thailand by Urban and Rural, Table 2.47 Trend of annual consumption of manufactured cigarettes in Thailand.. 55 Table 3.1 Mortality Attributable to Smoking, by Region 62 Table 3.2 Female Mortality from Cancer in 2000 for SEAR countries, World agestandardized mortality rate per 100,000 population, all ages Table 3.3 Female Mortality from cancer in 2000 World age-standardized mortality rate per 100,000 population, > Table 3.4 Age-standardized incidence rate of cancer per 100,000 population for females in countries of South-East Asia Region, Table 3.5 Mortality from Cancer, 2000, World Age-Standardized Mortality Rate per 100,000 population for Bangladesh, all ages 68 Table 3.6 Percentage distribution of cause of death for all age groups, Bhutan, Table 3.7 Mortality from Cancer, 2000 World Age-Standardized Mortality Rate per 100,000 population for DPR Korea, all ages Table 3.8 Tobacco-related Cancers, India. 72

8 Table 3.9 Tobacco-related Diseases, 1996, India. 73 Table 3.10 Ten Leading Causes of Mortality for Five Years 1996 to 1997, India 74 Table 3.11 Mortality rates and age-adjusted relative risks, by type of smokeless tobacco habit, among cohort study women, Mombai. 74 Table 3.12 Mortality rates and age-adjusted relative risks, by daily frequency of smokeless tobacco habit, among cohort study women, Mombai.. 75 Table 3.13 Mortality from Cancer, 2000 World Age-Standardized Mortality Rate per 100,000 population for India, all ages 75 Table 3.14 List of Disease, ICD-X International Statistical Classification of Disease and Related Health Problems, Tenth Revision Code and Estimated Proportion of Disease Attributable to Tobacco Indonesia Table 3.15 Number of Cases of Diseases attributable to tobacco by Gender, Indonesia, Table 3.16 Proportion of people exposed to environmental tobacco smoke inside the house, by age group and gender, Indonesia, Table 3.17 Number of Mortality Cases Attributable to Tobacco Use by Disease and Sex, Indonesia, Table 3.18 Mortality from cancer in 2000, Indonesia World age-standardized mortality rate per 100,000 population for Indonesia, all ages 83 Table 3.19 Tobacco-related diseases: Impatient by primary diagnosis IGM Hospital, Maldives, 2001 and Table 3.20 Ten leading causes of Mortality for five years 85 Table 3.21 Government Hospital admissions due to tobacco related diseases Table 3.22 Outpatients due to tobacco related diseases Table 3.33 Cancer cases admitted to Yangon General Hospital, Table 3.34 Total number of cancer cases treated at outpatient departments of Yangon General Hospital, Table 3.35 Mortality from cancer in 2000, MyanmarWorld age-standardized mortality rate per 100,000 population, all ages. 92 Table 3.36 Ten leading causes of Mortality related to tobacco for five years, Nepal Table 3.37 Causes of death in Nepal. 94

9 Table 2.38 Table 2.39 Table3.40 Table3.41 Mortality from cancer in 2000 World age-standardized mortality rate per 100,000 population for Nepal, all ages 95 Mortality from cancer in 2000 World age-standardized mortality rate per 100,000 population in Sri-Lanka, all ages.. 97 Number of Deaths and Deaths Rates per 100,000 Population, by 99 Smoking-Related Diseases in Thailand ( ). Mortality from cancer in 2000, World age-standardized mortality rate per 100,000 population for Thailand, all ages F I G U R E S Figure 2.1 Age specific prevalence of smoking among females by age group and region, Bangladesh, Figure 2.2 Trend of female smoking by age group Bangladesh (1996 to 2001).. 18 Figure 2.3 Types of tobacco products used in Bangladesh, Figure 2.4 Different types of tobacco products used among Females by Region, Bangladesh Figure 2.5 Trend of annual per capita consumption of manufactured tobacco, Bangladesh 1970 to Figure 2.6 Percent distribution of types of tobacco products used in Maldives, Figure 2.7 Percent distribution of types of tobacco use by sex group, Maldives, Figure 2.8 Age pattern of smoking among Myanmar women, Figure 2.9 Percent distribution of types of tobacco used in Myanmar, MSTE Figure 2.10 Percent Distribution of Types of Tobacco Used. 41 Figure 2.11 Percent Distribution of Types of Tobacco Use Within Sex Groups, Myanmar. 43 Figure 2.12 Female smoking by region, Nepal Figure 3.1 Female Age-standardized mortality rate per 100,000 population from cancer, all ages 65 Figure 3.2 Female Age-standardized mortality rate per 100,000 for >45 66

10 Acknowledgements I would like to express my gratitude to the Ministry of Health of Myanmar for allowing me to conduct the survey. My heartfelt thanks go to Dr. Wan Maung, Director General of the Department of Health, Dr. Hla Pe and Dr. Soe Aung, Deputy Directors General of Department of Health, Dr. Sawat Ramaboot and Dr. Khalil Rahman of WHO Regional office for South-East Asia, for their kind help and guidance for the study and to WHO country office of Myanmar for helping me with the process. I owe my gratitude to Dr. Narintr Timor of WHO Thailand and Dr. Sarah Barber of WHO Indonesia for arranging my meetings with tobacco focal persons and NGOs. I am very thankful to all the people who had answered the questionnaires and to those who had provided me information through and internet. I am indebted to all the participants of the WHO/WB Technical Regional Consultation on Effective Collaboration between the Health and Financial Sectors for Tobacco Control held in Jakarta, Indonesia from 3 rd to 4 th December 2003 who had provided invaluable information for the study. My sincere thanks go to my Director of Public Health, Dr. San Shway Wynn for his understanding and support throughout the study. I also owe my immense gratitude to my family and friends who had helped through the study. i

11 CONDUCTING THE STUDY This study was conducted with the technical and financial support of the Tobacco Free Initiative Unit of WHO Regional Office for South-East Asia. Dr. Sawat Ramaboot, Coordinator of Health Promotion Unit, and Dr. Khalil Rahman, Regional Tobacco Focal Point of SEARO provided inputs for conducting the study. The study started in June Most of the information for the study was obtained from reviewing of existing documents such as country reports, country profiles, WHO and other UN publications, articles published in international journals and from several websites. The tobacco control/global link website have provided invaluable information for the study. A lot of personal communications via had been conducted with tobacco activists of the Region who had been very kind and helpful to share any information they have on the subject. A questionnaire on the situation analysis of women and tobacco in the SEAR was developed by the author and sent to the WHO Regional Office for South-East Asia. Dr. Sawat Ramaboot and Dr. Khalil Rahman reviewed the questionnaire and gave comments and suggestions. In August 2003, after a few modifications to adjust country situations, questionnaires were sent to all WHO country offices through WHO Regional Office. Nine out of eleven countries filled in the questionnaires and returned back to the author through SEARO. The author visited Thailand and Indonesia in December In Thailand, meetings were arranged between the author and Tobacco focal point from WHO country office of Thailand Dr. Narintr Tima, Dr. Prakit Vattesatokit chairman of Action on Smoking and Health, Ms. Bung-on Rotthipakdee from Thai Health Foundation and other ASH staff, and Miss Ramida Russel (ex- Miss Thailand and ex-ash staff, an active anti-tobacco campaigner). In Indonesia, the author met with chairpersons and members of Central Committee for Tobacco Control, Indonesia Heart Foundation, Indonesia Cancer Foundation, and Indonesian Women against Tobacco. They willingly provided information on their ongoing activities and their views on the situation of tobacco control in Indonesia. During a workshop held in Jakarta from 3 rd to 4 th December, 2003, WHO/World Bank Technical Regional Consultation Effective Collaboration between the Health and Financial Sectors for Tobacco Control, the author had the opportunity to meet many focal persons from member countries. Not only did the participants of the workshop generously provided additional invaluable information for the study but they also gave very good suggestions for the report. During 2001 and 2002, WHO SEAR had helped countries to conduct very important surveys regarding to tobacco; sentinel prevalence surveys were conducted in Bangladesh, India, Indonesia, Myanmar, Nepal and Sri Lanka; economics studies were conducted in Bangladesh, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand. A lot of ii

12 information in this study was based on these country reports. Additional information was also obtained from country presentations at various Regional Consultation Meetings. The study was in fact, a systematic review of all the information obtained from existing documents and reports. Answers from the country focal points and organizations to the questionnaire had been very informative and meeting with focal persons from countries at Indonesia and Thailand provided much needed information for the study. iii

13 EXECUTIVE SUMMARY South-East Asia Region comprises of eleven countries: Bangladesh, Bhutan, Democratic Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor- Leste. The population in the South-Eat Asia Region is estimated to be a little over 1.6 billion in the year 2003, estimates of adult female population in the Region was about 460 million in the year 2000 which is expected to increase to 700 million by the year The current tobacco consumption rates in the Region ranges from 25.7% and 59.6% for men. Although female smoking prevalence in the South East Asia Region was considered to be low (except in Nepal, Bangladesh, Myanmar and Maldives) compared to global figures of around 12% for women, the number of women using tobacco in the Region was considerable, due to the huge size of female population in the Region. In 2000, it is estimated from the available data that there were more than 120 million women using at least one form of tobacco (smoking or smokeless) in the Region. In Bangladesh alone, estimates for 2001 showed that there were 8.5 million women smokers, most of them smoking bidis. In India, it was reported that one third of women used at least one form of tobacco, this came to around 100 million women above 15 years of age. Prevalence rates of tobacco use and pattern of types of tobacco use differ greatly in the Region. High prevalent rates of smoking and smokeless tobacco users were found in Bangladesh, Maldives, Nepal and Myanmar. Although low smoking rates were reported from India and Sri Lanka, prevalence of smokeless tobacco use was very high among Indian women and also high among the rural women of Sri Lanka. Smoking rates were low among Bhutanese, Thai, Korean, Sri Lankan and Indonesian women. Female smoking rates were increasing in India and Bangladesh; it has increased rapidly in Bangladesh mainly among the poor; in India female smoking has nearly doubled in the urban areas and increased by 60% in the rural areas. Declining trends of female smoking rate were found in Thailand and Maldives. The pattern of smoking among women was quite different in the Region compared to developed countries. Despite fears of western influence and less social stigma against women smoking, it has yet to become a fashionable and modern habit among educated and urban women in most countries of the Region. Smoking is still a men thing; it has been accepted as a norm for adult men for centuries and is still a male behaviour in most countries of South-East Asia. The majority of women smokers belong to the poor and uneducated and rural areas have higher prevalence than the urban areas. In Bangladesh, not only prevalence of smoking is higher among the poor, consumption is also increasing sharply. Cigarette consumption, which is used mainly by the relatively well off and the educated was declining whereas consumption of bidis among the poor has sharply increased over the years. General trend iv

14 also shows increasing expenditure on tobacco by poor women; during 1995 to 1997, the potential in calories of rice for the average tobacco user nearly doubled for Bangladeshi women. In Maldives where smoking is very much part of Maldivian culture, prevalence of female smoking (29.4% in 1997 and 15.6% in 2001) is among the highest in the Region. Tobacco use is also widely practiced among rural women in Nepal (29%) and Myanmar (21.9%) where it has been culturally and socially accepted since ancient times. Smoking of cheroots and hand-rolled cheroots is commonly practiced among Myanmar rural women and mostly in the older age groups. Smoking rates among women greatly differ between regions in Nepal; it is highest in the mountains, followed by the mid-hills and the Tarain. The majority of smokers in Nepal smoke cigarettes, a few smoke bidis and hukkah. Nepalese women smoke much cheaper products such as bidis than males. Among smoking products, kretek (clove cigarette) is unique of Indonesia and is reported to be more harmful than white cigarettes. Literacy also greatly affects smoking rates. In Nepal, female literate population is four times less likely to smoke than the illiterates. Exceptions are found in Thailand, where relatively higher rates of female smoking were found among certain professionals such as business women, air hostess, women working in beauty saloons and women educated in other countries; and in Bhutan where smoking was higher among the educated and in urban areas. In countries like India and Bangladesh, where smokeless tobacco use was very common among females, women started tobacco use with smokeless products unlike men. India was unique in having many varieties of smokeless tobacco products; although only a few women smoke (2.5% in ) a large percentage (12.4%) of women use smokeless tobacco products. A 1997 survey in Mumbai reported 57.5% of tobacco use among women, consuming exclusively of smokeless tobacco products. A very high percentage of Bangladeshi women (47%) also used betel quid and chewed dried tobacco leaf (26%). Around 20% of tobacco users in Nepal and 2.9% of tobacco users in Myanmar consumed smokeless tobacco. In Sri Lanka, smokeless tobacco use was practiced only among the females in rural areas, and is considered as village behaviour. In the villages, a high percentage of women were found to chew betel quid and also chewing of raw tobacco. Many studies have reported the negative health consequences of tobacco use among women. It has been estimated that women smokers who die of a smoking related disease lose on average 14 years of potential life. Use of tobacco, including smokeless tobacco, is estimated to have caused more than 100,000 female deaths in developing countries in It is also estimated that women will account for an increasing proportion of all smoking- v

15 attributable deaths in coming years. The gender gap between men and women closes as smoking prevalence in women approximates that of men. Worldwide, it is estimated that tobacco causes about 8.8% of deaths (4.9 million) and 4.1% of DALYs (59.1 million). As smoking is more common among males than females worldwide, attributable mortality is greater in males (13.3%) than females (3.8%). Approximately 16% of the global attributable burden occurred in the South-East Asia Region. World Health Organization estimates that approximately 500,000 tobacco-related deaths occurred in the South-East Asia Region. This estimate is much lower than estimates done by countries, the estimate for tobacco attributable mortality was between 630,000 to 800,000 for India and more than 570,000 for Indonesia and 14,000 for Nepal. In India 4% of all deaths among women was estimated as related to tobacco. In Indonesia over 200,000 female deaths are attributable to tobacco each year. In Thailand, 42,000 deaths were attributed to tobacco in Worldwide in 1990, approximately 10% of female cancer deaths resulted from smoking. Tobacco-related cancers account for about half of all cancers among men and onefourth among women. Oral cancers account for one-third of the total cancers, with 90% of the patients being tobacco chewers. India had one of the highest oral cancers in the world. The highest reported incidence rate in the world for cancer of the mouth is among women in Bangalore, India, where women have considerably higher rates than men; this pattern is also found in Madras again in India. A much higher incidence of oral sub-mucous fibrosis was seen among women in India. Tobacco-related cancers account for one-fourth of all cancers among females in India. Estimates from 2001 data in Indonesia demonstrate that tobacco contributes to 193,666 cases of cancer (all types) of which the majority are lung cancer cases (96,163); in addition, tobacco accounts for 31,847 deaths annually due to lung cancer. Cancer mortality in Myanmar is apparently affecting not only males, as in all SEA countries, but also females. This is explained by female mortality rates that are higher than in most other countries of the Region. Oral cavity, oesophagus and lung cancers are the major killers among both males and females in Myanmar. According to GLOBOCAN, age-specific female lung cancer death rates are highest in Myanmar followed by Thailand. Oral cavity cancer deaths are highest in Bangladesh followed by Sri Lanka, Nepal and India. In Sri Lanka, figures for showed that about 10% of all cancers in the total population were related to tobacco use. The incidence of cancer in women that could be related to tobacco use increased from 1 per 100,000 population in 1985 to 1.57 per 100,000 in vi

16 The incidence of lung cancer among Northern Thai women is one of the highest in Asia and among the highest in the world, with an annual age-adjusted incidence rate of 37.4 per 100,000. In all countries of the Region, except in Thailand and Bhutan, smoking prevalence rates among men are very high, usually above global figures. As the majority of smokers smoke at home and public places, there is an ever-increasing incidence of lung cancer among women and non-smokers exposed to environmental tobacco smoke. In Bangladesh, Nepal and other countries, high incidence of ARI cases were reported among children exposed to ETS. Indoor air pollution due to use of fuel and exposure to tobacco smoke and other fumes contributed to high incidences of ARI cases among children in the Region. Perinatal deaths, abortions and low-birth weight babies are also reported due to maternal smoking and passive smoking. Stillbirths, low-birth weight babies and prenatal mortality have been reported among female tobacco chewers as well. In Bangladesh, women who were passive smokers of bidis during pregnancy had twice the number of perinatal deaths than those women from similar characteristics but who were married to companions with no tobacco habit. Smoking has also been identified as one of the major risk factors for hypertension in India. Indonesian data demonstrates that more than 3 million cases of tobacco attributable to cardiovascular diseases annually, in addition to more than 190,000 deaths. Various retrospective studies in Indonesia, relates smoking behaviour with higher incidence of cardiovascular diseases (including stroke), and respiratory tract infection and cancer. India estimates that there were 4.21 million females suffering from COPD each year. Overall, more than ½ million Indonesian suffer from respiratory diseases annually due to tobacco use, and more than 90,000 die from these conditions. In India alone, there was an estimate of 10 million workers employed in the tobacco industry, approximately 60% of them are women and 12% to 15% of them are children, mainly young girls. Although there is no data on women employed in tobacco business for the Region, it is estimated that 10 to 12 million females are engaged in a wide range of tobacco industry from planting, weeding, picking, binding and tying of tobacco leaves to rolling of bidis and cheroots. These workers have to suffer from various health and social consequences arising from long hours of monotonous work in unhealthy, crowded conditions. Common disorders include rheumatic joint pains, stomach troubles, back-aches, impaired vision, piles, chronic cough, tuberculosis, stunted growth etc. and women and young girls are also deprived of labour rights in many bidi industries. Green tobacco sickness is also reported from Indonesia. Each country in the Region has its own tobacco control policy and government and state institutions are working hand in hand with UN and international agencies, local and vii

17 international NGOs towards tobacco control. Countries have also different stages of tobacco legislation; Thailand has success stories in the area of tobacco legislation, India has recently enacted a comprehensive tobacco control law, Myanmar and Nepal are in the process of coming up with tobacco control laws. Many countries have set rules and regulations, mainly to protect nonsmokers health from being exposed to Environmental Tobacco Smoke. Quite a few NGOs in the Region such as Action on Smoking or Health of Thailand had taken innovative actions and motivated and pushed governments to come up with tobacco control policies and legislation. Thailand has its own programme known as Thai women do not smoke. This project and many other activities had been proved to be successful to counteract the tobacco industry s techniques to lure women into the habit of smoking cigarettes. Country programmes should set such targets to prevent young girls from experimenting tobacco. In the mean time, as most of the tobacco users in the Region belong to the poor and the uneducated, programmes should aim at educating the poor and promoting their health. Female education plays a very important role. Community awareness campaigns should be aimed to reach the grassroots level. Community-based cessation of tobacco use programmes should be expanded to the rural areas, where women of older age group spend their time and their hard-earned scarce resources on tobacco. viii

18 INTRODUCTION It is well known that smoking of tobacco products began as a habit of men in developed countries and has been adopted by women in those countries at a later stage. Men in developing countries followed the habit of smoking and only recently have women in developing countries begun to smoke, although the use of smokeless tobacco has been taking place among them much earlier. The epidemic of tobacco-related diseases had expanded from developed to developing countries and tobacco use is increasingly becoming a major health issue for women as well as men. 1 WHO estimates that there are currently 4.9 million deaths a year related to tobacco, a figure expected to rise to more than 10 million by the year 2030 with 70% of them in the developing countries. By 2030, tobacco will account for more deaths than the total deaths from malaria, maternal conditions, and injuries combined. According to WHO estimates in 1995, there are about 1.1 billion smokers in the world, representing about one-third of the global population aged 15 years and over. The vast majority of the smokers are in developing countries (800 million) and most of these are men (700 million). Overall consumption has fallen among males in most high-income countries but it is on the increase among males in low- and middle-income countries and among females worldwide. About one-third of regular smokers in developed countries are women, compared with only about one in eight in developing countries. 2 Global estimates in 1995 indicate that about 12% of women smoke compared to about 47% of men. It was estimated that about 236 million women in the world were daily smokers in About 22% of women in developed countries and 10% of women above 15 years of age in developing countries smoke tobacco. 3 Unless new, innovative and sustainable initiatives were implemented, it is predicted that prevalence of female smoking in both developed and developing countries will be around 20% by 2025 with the number of women smokers in the world rising to 532 million. The tobacco industry is targeting women with alluring campaigns and with women s increasing spending power making cigarettes more affordable for them, the prevalence of smoking among women in developing countries is predicted to increase. The female population in developing countries will rise from the present 2.5 billion to 3.5 billion by 2025, so even if the prevalence remains low, the absolute number of women smokers will increase. 4 This huge increase in the number of women smokers around the world will have enormous consequences on health, the economy, the family and the environment. In addition to smoking; women also chew tobacco and use other forms of smokeless tobacco. In countries like India, prevalence of smokeless tobacco use was five times higher than smoking rates among women. Scientific evidences show that smokeless tobacco use is highly related to oral cancers. 1

19 Tobacco use and tobacco related illness is a serious health problem in the South- East Asia Region even at present. The current consumption rates ranges from 25.7% to 59.6% of men and although female smoking prevalence in the South East Asia Region was considered to be low (1.7% to 6.7%) except in Nepal (29%), Bangladesh (21% ), Myanmar (21% ) and Maldives (15%); recent prevalence reports from countries like India and Bangladesh show increasing prevalence among females. Indonesia is ranked as having the fifth largest number of smokers in the world, while in India and Thailand it has been estimated that there are approximately 240 million and 11 million tobacco users. In Bangladesh there are estimated 20 million smokers, 5 million of them women in 1996, in the year 2001 it was estimated that there were 8.5 million women smokers. 5 Smokeless tobacco use remains high in India, Bangladesh, Myanmar and Nepal although it is very low in Thailand and Sri-Lanka except in certain regions. South-East Asia Region has become a lucrative market for tobacco industry. Tobacco consumption in the Region is increasing rapidly, especially among the youth and the poor. India accounted for 65% of the Region s total tobacco leaf production in which increased to 71% in Indonesia continues to be the largest producer of cigarettes in the Region, followed by India, Thailand and Bangladesh. Indonesia, Thailand and India were among the world s largest cigarette consumers in 1994 accounting for 5.7% of the world s total. Although India ranked only 14 th for manufactured cigarette consumption, if the estimated amount of bidis consumed is added to the amount of cigarettes consumed, India ranks second globally in total cigarettes/bidis consumption. 6 Even though females consume much less proportion than men, the effects of environmental tobacco smoke on women and children should be seriously taken. The effects of passive smoking are more pronounced in the South-East Asia Region where the high level of nicotine and tar levels in cigarettes, bidis and kreteks, the poor implementation of laws banning smoking at public places and high incidence of indoor smoking put non-smokers as well as women and children at a high risk of tobacco-related diseases. WHO estimates that there are approximately 500,000 tobacco-related deaths in the Region 6. India has one of the highest incidences of oral cancers in the world. Tobacco related cancers account for about half of all cancers among men and one-fourth among women. Tobacco-related illnesses such as cancer, cardiovascular and respiratory diseases are already major problems in most countries in the Region. Approximately half of all cancers in men in India are tobacco related, while over 60% of those suffering from heart disease below the age of 40 are smokers. There is an estimated 12 million cases of preventable tobacco related illnesses each year in India. In Sri Lanka, it is estimated that over 43% reported of cancers are tobacco related. Oral carcinoma is the most prevalent 2

20 form of cancer in Sri Lanka and cardiovascular diseases is the leading cause of death. Thailand reports 10,000 cases of tobacco related lung cancer each year. In India, tobacco attributable mortality has been estimated to be 80,000 per year while in Indonesia; in 2001, (21%) of all deaths were attributable to tobacco, and is expected to rise dramatically within the next few decades. According to a report by the Ministry of Health of Republic of Indonesia, the estimated number of mortality cases attributable to tobacco use in the year 2001 was 412,964; 211,271 males and 201,693 females. 7 Women constitute 60% of the work force of many bidi and cheroot making industries in the Region and suffer tobacco-related occupational hazards such as backaches, stiff joint pains, chronic asthma, tuberculosis, fatigue and weakness, mental trauma, stunted growth etc. In Indonesia, a study found that the incidence of Green Tobacco Sickness is 63.7% among tobacco farmers. Common complaints of green tobacco sickness include dizziness, headache and fatigue. 7 It is estimated that in India about 6 million roll bids and 4 million collect leaves. Since it involves working at home it includes children especially girls. In all steps of bidi workers 65% happen to be women and there are 15% children mostly girls. Women are paid less than men and children the least of all for the same work. As a huge percentage of women and children are illiterate, the employers can take advantage of them and they cannot fight back as a group for their rights. 8 Many research studies had been conducted on the issue of women and tobacco. These studies reported issues specific to women regarding to initiation, maintenance and cessation of tobacco use. It was often stated that women are less likely to plan to quit smoking than are men and are harder to quit also. Other studies reported that although women quit smoking at the same rate as men, they are less able to maintain cessation long-term. Men started to smoke for reasons such as peer pressure, parental smoking, rebellious behaviour etc. whereas women are more likely to smoke for tension reduction, depression, family violence, and fear of weight gain. This study tries to analyze the situation of women and tobacco in South-East Asia Region. There is very limited data available; most of the data available are from surveys with different designs which could not be compared scientifically. There is also very limited data on women employed in tobacco industry, the extent of women exposed to ETS, and the tobacco-related morbidity and mortality. However, all available information has been compiled and recorded with the hope to be served as a baseline for further studies and for planning and monitoring of tobacco control programmes in the Region. 3

21 References 1. Virginia L. Ernester. Impact of Tobacco Use on Women s Health. In WHO: Women and the Tobacco Epidemic, Challenges for the 21 st Century. WHO in collaboration with the Institute for Tobacco Control, Johns Hopkins School of Public Health. Canada, World Health Organization. Tobacco or Health: A Global Status Report. Geneva, World Health Organization, Ranson K, Jha P, Chaloupka F, Yurekle A. Effectiveness and cost-effectiveness of price increases and other tobacco control policy interventions. In Jha Prrabhat, Frank Chaloukpka. (Eds). Tobacco Control Policies in Developing Countries. New York: Oxford University Press, Dr. Judith Mackey. Preface in Women and the Tobacco Epidemic, Challenges for the 21 st Century. WHO in collaboration with the Institute for Tobacco Control, Johns Hopkins School of Public Health. Canada, Bangladesh Institute of Development Studies. Craving for Nicotine: A study on Tobacco Prevalence in Bangladesh. Dhaka..June World Health Organization, Regional Office for South-East Asia Region: Health Situation in the South-East Asia Region World Health Organization, Regional Office for South-East Asia Region New Delhi, Ministry of Health Republic of Indonesia: The Tobacco Source Book: Data to Support a National Tobacco Control Strategy. English Summary, December 3, Mira B. Aghi. Women, Children and Tobacco. Paper presented at the WHO International Conference on Global Tobacco Control Law, New Delhi, India, January World Health Organization, Regional Office for South-East Asia Region: Women of South-East Asia: A Health Profile. World Health Organization, Regional Office for South-East Asia Region New Delhi,

22 PART ONE: BASIC INFORMATION The WHO South-East Asia Region comprises eleven countries and is characterized by diversity in geographical, meteorological, economical, social and cultural aspects. It comprises of Bangladesh, Bhutan, Democratic Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor Leste. Countries in the Region range in size from Maldives with an area of around 300 square kilometers to India with a land area of over 3 million square kilometers. There is great variety in physical features as well, including an island nation (Sri Lanka), the world s largest (Indonesia) and among the smallest (Maldives) archipelago countries, the predominantly flat alluvial plains of Bangladesh, and the world s tallest mountain ranges in India and Nepal. Demography The population in the South-East Asia Region is estimated to be a little over 1.6 billion in 2003 and is projected to increase to over 1.75 billion in the year Although the population in the South East Asia Region as a percentage of the world s population has declined from 26.11% to 25% over the last decade, the UN s medium variant projections indicate that this share will increase to 26.03% by Countries of the Region vary widely in terms of population size. Maldives has a population of a few hundred thousands; Bangladesh and Indonesia have more than a hundred million each, while India reached a landmark in 2000 when its population exceeded one billion. Bangladesh, India and Indonesia are among the most populous countries in the world, and account for 88.2% of the world s population. 1 The Region is the most densely populated region in the world; in 2000, at 222 persons per sq km, was almost five times the global figure. Bangladesh and Maldives were the most densely populated countries, while Bhutan and Myanmar were the least Table 1.1. Estimate of adult female population in the Region in 2000 was about 460 million which will increase to 700 million by the year Except Myanmar and Thailand, population of males exceeds that of females in all countries. In some countries (Bangladesh and India) the relatively higher proportion of males in the population is at least in part due to the higher female than male mortality during childhood and in the reproductive age group. In DPR Korea, the sex ratio males per 100 females is projected to change in favour of females by Countries in the Region have undertaken substantial efforts to reduce the growth of their populations. The average annual population growth rate for the Region as a whole has steadily declined from 2.14% in to 1.66% in The age distribution of the population is rapidly changing in SEAR countries as in many developing countries. Adults in the working age group years have become an increasing proportion of the general population, while the proportion of the population aged 65 and above has also increased. In 2000, 33.2% of the population belongs to 0-14 age group, 62% belongs to 15 to 64 age group and 4.8% belongs to over 65 years age group. 2 5

23 Table (1.1) Demographic Indicators of South-East Asia Region Country Mid-2003 population (millions) Sex Ratio (Males per 100 females) for 2000 Annual Growth Rate% 2002 % Urban 2003 Population density (per sqkm) 2000 Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste SEAR Sources: 1: UNITED NATIONS, World Population Prospects, The 2002 Revision (New York, 2003) 2. ESCAP: Estimates based on available data 3. Bangladesh Bureau of Statistics, Population Census 2001, Preliminary Report, Ministry of Planning and National Development, Maldives: Statistical Year Book, Maldives ) 5: Nepal, Population Census 2001; National report(kathmandu Central Bureau of Statistics, 2002) and Nepal Demographic and Health Survey 2001(Alverton, Maryland, USA) 6: Thailand; Estimates Provided by the Institute for Population and Social Research Nakhon Pathom, Mahidol University WHOSEARO: Women of South East Asia: A Health Profile, WHOSEARO, WHO SEARO : Health Situation in the South-East Asia Region, WHOSEARO, Statistical Year Book

24 Table (1. 2) Female adult population 15 years and above (millions) Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste Source: United Nations Population Division, World population Prospects (2000 Revision) Health Status Indicators Life expectancy and mortality rates are the most commonly used indicators of a population. Life expectancy at birth is a hypothetical measure expressing the average number of years a newborn can be expected to live if the current mortality trends continue. It indicates the current health and mortality conditions in a population. Female life expectancy at birth varies widely among the Region from 58.3 years in Nepal to 75.4 years in Sri-Lanka. DPR Korea, Thailand, Maldives and Sri Lanka have female life expectancies of above 70 years. In other countries, female life expectancy is between 58 to 63 years, low when compared to countries of East and South-East Asia such as China 70.5 years and Malaysia 73.1 years. Except Maldives and Nepal, female life expectancy is higher than male life expectancy like almost all countries of the world. Bangladesh, Bhutan, India, Maldives, Myanmar and Nepal have high Crude Birth Rates which are well above the global rate of 21.2 per 1,000 population (Table 1.3). Sri Lanka and Thailand had Crude Birth Rates below the global average and is expected to reduce their birth rates by 30% over

25 A considerable decline in mortality has been recorded in South-East Region over the years. Between the period and , the crude death rates are projected to decline in all countries except DPR Korea. Table (1. 3) Health Status Indicators in South-East Asia Region Country Crude Birth Rate (per 1,000 population) 2002 Crude Death Rate (per1,000 population) 2002 Life expectancy at birth (years)reported ( ) Male Female Bangladesh Bhutan DPRKorea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor Leste SEAR World Source: United Nations Population Division, World population Prospects (2000 Revision) Rates for infant mortality and under five mortality per 1,000 live births and maternal mortality ratio per 100,000 live births are shown in Table 1.4. These data are different from country reports but are taken from the same source to have a consistent view. Bangladesh and Nepal have very high maternal mortality ratio, Myanmar, Nepal, Bangladesh and India have high infant and under five mortality rates. Sri-Lanka and Thailand have low mortality rates compared to other countries in the Region. When infant and child mortality rates were differentiated by sex in countries where information is available, it was found that all countries of the Region had a higher male infant mortality although female post-neonatal mortality rates exceeded that for 8