Patterns of smoking in Russia

Transcription

1 22 Europea Cetre o Health of Societies i Trasitio, Lodo School of Hygiee ad Tropical Medicie, Lodo, UK M McKee L Cheet D Leo Uiversity College Lodo, Lodo M Bobak Cetre for the Study of Public Policy, Uiversity of Strathclyde, Glasgow R Rose Ceter of Demography ad Huma Ecology, Istitute for Ecoomic Forecastig, Moscow, Russia Federatio V Shkolikov Correspodece to: Professor M McKee, Europea Cetre o Health of Societies i Trasitio, Lodo School of Hygiee ad Tropical Medicie, Keppel Street, Lodo WC1E 7HT, UK. m.mckee@lshtm.ac.uk Patters of smokig i Russia Marti McKee, Marti Bobak, Richard Rose, Vladimir Shkolikov, Lauret Cheet, David Leo Abstract Backgroud Tobacco is a leadig cause of avoidable death i Russia but there is, as yet, relatively little iformatio i the public domai o who is smokig ad how this is chagig. This iformatio is importat for those seekig to develop evective policies to tackle this issue. Objective To determie the prevalece of smokig i Russia ad its associatio with sociodemographic factors. Desig Cross-sectioal survey o patters of tobacco cosumptio. Settig Data were collected usig the New Russia Barometer, a multi-stage stratified-sample survey of the populatio of the Russia Federatio udertake i the summer of Participats Data were available o 1587 idividuals (respose rate 65.7%). Respodets divered little from the overall Russia populatio i terms of age, sex, educatio, ad votig itetio. Mai outcome measures Prevalece of curret ad past smokig. Results Smokig is commo amog males of all ages ad i all areas. Of those aged years, 65% smoke, risig to 73% i those aged ad the fallig steadily to reach 41% i those aged 65 ad older. Amog wome, smokig is much more commo amog the youg (27% i those aged 18 34) tha amog the middleaged ad elderly (5% i those aged 55 ad older), ad more commo amog those livig i urba areas tha i rural areas. Smokig is also more commo amog me ad wome suverig material deprivatio but there is o idepedet associatio with educatio. Amog me, but ot wome, church attedace is iversely associated with smokig. I both sexes, but especially wome, heavy drikig ad smokig are associated. Coclusios Tobacco poses a major threat to the health of future geeratios i Russia, especially amog wome. A robust policy respose is required. (Tobacco Cotrol 1998;7:22 26) Keywords: prevalece, Russia, smokig Itroductio Tobacco cosumptio i Russia faces further upward pressure as trasatioal tobacco compaies take advatage of the opportuities arisig from the opeig of markets. 1 This is i a coutry i which rates of smokig-related death are already high ad have bee climbig. Usig a method based o estimates of the fractio of particular causes of death attributable to smokig, Peto et al 2 estimated that smokig accouted for 30% of all male deaths (42% i the age group years) but oly 4% of female deaths (6% i the age group 35 69) i the Russia Federatio i This equates to a average of 17 years of life lost per death from smokig. Expressed i aother way, they estimate that more tha oe i five Russia me aged 35 will die from disease attributable to smokig before reachig age 69, based o 1990 death rates. These figures idicate the importace of tobacco as a cause of premature death i Russia ad the eed for a evective policy respose. The preset survey seeks to determie the prevalece of smokig i a atioally represetative sample of the Russia populatio ad to obtai iformatio o sociodemographic factors associated with smokig. This iformatio, which has previously bee uavailable, will be ecessary for the developmet of such a respose. Methods The New Russia Barometer (roud 6) was udertake by the Russia Cetre for Public Opiio Research (VCIOM) betwee 25 July ad 2 August The methods have bee described i detail elsewhere 3 but, i brief, it was a multistage, stratified sample of the populatio of the Russia Federatio i which the Federatio was first divided ito 22 regios, the ito urba ad rural areas, ad the, for urba areas, by populatio to give regioal cetres ad other tows. Withi that framework, tows were radomly selected with a probability equal to their share of the total populatio. A total of 69 urba ad rural settlemets were selected. A total of 161 traied iterviewers were used. Uit Table 1 Characteristics of sample compared with Goskomstat populatio estimates for 1993 Variable Tobacco Cotrol 1998;7:22 26 Actual (%) Age (years) > Educatio Higher Techical Secodary Vocatioal Icomplete secodary ad less Expected % (based o Goskomstat estimates) Tob Cotrol: first published as /tc o 1 March Dowloaded from o 2 July 2018 by guest. Protected by copyright.

2 Patters of smokig i Russia 23 Table 2 Smokig status of Russias (%) Age group (years) Ex- Ex > households were listed i address order ad, startig with a radom selectio, with idividuals matchig a age by geder by educatio grid. The survey was desiged primarily to assess sociodemographic, ecoomic, ad political factors but also cotaied some questios o health. The data o which this paper is based are derived from the questio: Do you smoke ow? (yes/o), ad if ot: Did you smoke i the past? (yes/o). From resposes to these questios, idividuals were categorised as curret s, ex-s, or evers. Questios o alcohol cosumptio examied frequecy of drikig ad quatity, expressed as commoly uderstood measures of vodka, wie, ad beer. These were subsequetly coverted to quatities of pure alcohol. Results Of 3379 households with someoe at home, 965 (29%) had o-oe who met the requiremets of the grid; i 470 (20%) the iterview was refused; i 271 (11%) the door was ot aswered; i 63 (3%) the idetified idividual was uable to aswer; ad 11 (0.4%) iterviews were iterrupted. I total, 1599 iterviews were completed. For 12 idividuals, age was ot recorded ad these were excluded from the aalyses. This gave a overall respose rate of 65.7%. The fial sample was a close match with data from Goskomstat for the populatio i 1993 i terms of geder, age, ad educatio divisios (table 1), ad questios o votig itetios also correspoded closely with the actual votes cast i the 1996 electio. Amog me, smokig is very commo i those aged uder 50. It declies relatively steeply amog older groups, reflectig largely the relative icrease i ex-s (table 2). Amog wome, few over age 50 have ever ad eve fewer (6 7%) are curret s. The frequecy of curret smokig Table 3 Settlemet Smokig status (%) by type of settlemet Ex- decreases cosiderably with icreasig age. If it is assumed that most s begi i their tees, the figures for those who have ever would be cosistet with a iterpretatio that smokig rates amog me may actually be fallig i youger age groups but that, amog wome, they are risig quite rapidly. Whe aalysed by type of settlemet, there is very little diverece amog me, but amog wome, curret smokig is much more commo i Moscow ad other cities tha i rural areas (table 3). Aalysis by regio agai shows little variatio amog me but also shows cosiderable divereces amog wome, with higher levels i the area aroud Moscow ad i Siberia tha i Souther Russia, eve after adjustig for urbaisatio (results ot show). Logistic regressio was udertake to explore the associatio with a variety of possible explaatory variables. The results are show i table 4. The defiitios of most of the variables are self-evidet but material deprivatio requires commet. This is a composite variable calculated from resposes to questios o whether those i the respodet s family had ofte (scored as 3), sometimes (2), rarely (1), or ever (0) had to go without food, heatig, or ecessary clothes i the precedig 12 moths. I the iterests of brevity, the sum of these scores, ragig from 0 9, have bee reduced to quartiles, with quartile 1 the least deprived ad quartile 4 the most deprived. I summary, this table cofirms the absece of a evect of habitatio for me ad a marked urba/rural diverece for wome. It shows a more complex patter for educatio, with me ad wome completig secodary educatio most likely to smoke, with lower rates amog those completig uiversity educatio. Smokig is also very strogly correlated with heavy drikig ad is more commo i those who have experieced deprivatio. Although ot show i the table, the test for liear tred of smokig with deprivatio whe all 10 categories are used is highly sigificat (p<0.01) for both sexes. Church attedace is sigificatly egatively associated with smokig for me (p<0.02 for tred) but ot wome. Other aalyses, ot show here, show o associatio with perceived ability to ifluece oe s health, self-declared ethic origi, or view o whether the ecoomic situatio of oe s family will be better i five years. Ex- Moscow Oblast* capital >0.5 millio populatio Oblast* capital <0.5 millio populatio Other tow Rural *Oblasts are the stadard regios i the Russia Federatio, typically with a populatio of about 3 5 millio. Tob Cotrol: first published as /tc o 1 March Dowloaded from o 2 July 2018 by guest. Protected by copyright.

3 24 McKee, Bobak, Rose, et al Table 4 Variable Factors associated with probability of beig a curret Odds ratio (95% CI) Residecy Moscow *Oblast capital >0.5 millio populatio 0.79 ( ) 0.51 ( ) *Oblast capital <0.5 millio populatio 0.82 ( ) 0.28 ( ) Other tow 0.96 ( ) 0.26 ( ) Rural 0.86 ( ) 0.15 ( ) Educatio Primary Vocatioal 1.41 ( ) 1.39 ( ) Secodary 1.09 ( ) 1.26 ( ) Uiversity 0.63 ( ) 0.73 ( ) Alcohol itake <0.25 litres at least twice a moth >0.25 litres at least twice a moth 2.31 ( ) ( ) Material deprivatio Quartile 1 (least deprived) Quartile ( ) 0.97 ( ) Quartile ( ) 1.62 ( ) Quartile 4 (most deprived) 1.69 ( ) 2.00 ( ) Church-goig Very rarely 0.93 ( ) 1.25 ( ) Occasioally 0.59 ( ) 1.23 ( ) At least oce a moth 0.51 ( ) 0.73 ( ) Each variable adjusted for all others listed i the table. *Oblasts are the stadard regios i the Russia Federatio. See text for defiitio. Table 5 surveys Age group (years) Prevalece of smokig (%) i Russia from other RLMS VI Karelia study NA NA > NA NA Sources: Russia Logitudial Moitorig Survey (RMLS) 4 ; Karelia study. 5 NA = data ot available. Discussio The atioal coverage, ad i particular the coverage of rural areas, ad the ability to lik results with demographic ad socioecoomic characteristics, eable these data to provide valuable ew iformatio about the patter of smokig i Russia. Before discussig the results it is ecessary to cosider the represetativeess of the sample, as the respose rate was lower tha desired. It is possible that o-respoders divered from respoders i terms of tobacco cosumptio. Give the observed associatio betwee smokig ad heavy drikig ad the kowledge that those who drik heavily are least accessible to surveys, it is possible that we have uderestimated the prevalece of smokig. Coversely, the close agreemet with the characteristics of the populatio, as estimated by Goskomstat, ad with observed votig patters, suggests that the sample is broadly represetative of the Russia populatio. The overall patters of smokig foud i this study are similar to those i other recet surveys, summarised i table 5. For the first compariso, we have aalysed data from roud 6 (udertake i 1995) of the Russia Logitudial Moitorig Survey, a periodic survey of betwee ad subjects begu i Data are i the public domai ad accessible via the iteret, 4 where full details of the survey methods are provided. The secod source is a survey of a radom populatio sample udertake i 1992 of the populatio of Russia Karelia aged betwee 25 ad Both surveys cofirm the much higher frequecy of smokig amog me tha wome at all age groups ad, amog wome, the much higher frequecy amog the youg. The frequecies amog me are broadly similar i each survey, but the Barometer data give slightly higher frequecies for wome. DiVerece i timig or i regioal patters might explai the lower rates reported i the earlier Karelia study but the reasos for the lower frequecies i the Russia Logitudial Moitorig Survey are ot obvious. I both cases, however, it is possible that there may be evects from mior divereces i the wordig of questios or to chace. The relative absece of historical data makes it impossible to determie treds with accuracy, although the age distributio i these studies is cosistet with higher rates of smokig i the curret geeratio. Oe of the few examples of studies from the Soviet period is from the MONICA study, 6 which reported that, i a survey amog those aged i Moscow ad Novosibirsk durig , betwee 46% ad 48% of me ad betwee 3% ad 12% of wome. The frequecy was higher amog me i Moscow ad amog wome i Novosibirsk. These results are cosistet with the few other sources available. A article usig data from 1989 cites figures of 44% for me ad 10% for wome 7 but does ot specify the age rage icluded. Other research provides more iformatio o smokig amog youg people. A survey of 4594 school childre i Nal chik (86% respose) reported that 38.2% of boys ad 11.8% of girls at least oe cigarette per week. 8 It was reported that there was very little awareess of the adverse health evects of smokig. A earlier survey of smokig amog Moscow school childre foud a prevalece of smokig at least oe cigarette i the previous three moths equal to 14.4% of boys aged 10 11, risig to 53.2% amog those aged The correspodig figures for girls were much lower, at 0.8% ad 28.2% respectively. 9 Oe small study reported that smokig is more prevalet amog maual workers i Russia. 10 These results idicate that, amog me, smokig varies relatively little with area of residece, urba/rural residece, or educatio. A possible explaatio might be the extesive mixig of the populatio that has occurred durig military service, although this explaatio is purely speculative. I cotrast, there is cosiderable variatio amog wome that ca be summarised broadly as showig much lower rates of smokig i more traditioal areas ad higher rates amog those exposed to wester iflueces. This, take with the much higher prevalece i youger wome Tob Cotrol: first published as /tc o 1 March Dowloaded from o 2 July 2018 by guest. Protected by copyright.

4 Patters of smokig i Russia 25 ad the observatio that few i these age groups would have i previous geeratios idicates the potetial for a substatial growth i smokig-related diseases i the future. It will clearly be of great importace to uderstad better the factors uderlyig this observatio, such as how smokig is perceived ad accepted. This will require detailed qualitative research. The very strog associatio betwee smokig ad heavy drikig amog wome deserves commet. Work o patters of alcohol-related mortality i Russia suggests that, for me, there is a relatively smooth gradiet across educatio ad employmet categories whereas, for wome, the adverse cosequeces of alcohol are cocetrated i a small, relatively margialised group. 11a I the preset study, oly 3.3% of wome were categorised as heavy drikers. Our results suggest that these wome are also much more likely to smoke. The fidig of a higher percetage of evers amog the oldest group of me could reflect the cosequeces of high death rates amog s uder age 65, ot oly from smokig-related diseases but also from alcohol, give the evidece of a associatio betwee the two, although this is speculative. The results suggest that tobacco will make a icreasigly great cotributio to ill health ad premature mortality amog wome, for whom smokig has traditioally bee rare. Youg wome are the pricipal targets of promotioal evorts by trasatioal tobacco compaies. The respose to this threat has bee limited. Although, oycially, tobacco advertisig was baed i the Soviet Uio i 1980 ad sales of cigarettes to those uder age 16 was prohibited i 1981, these measures have bee widely flouted. 11 I 1993 a further ba o tobacco advertisig i the Russia Federatio was approved by the Duma (the Lower House of the Russia Parliamet) but the press miistry refused to support it because of the reveue cosequeces. Subsequetly the Associatio of Russia Advertisers lobbied agaist the ba, reportedly with fiacial support from the tobacco idustry. 12 I 1995, the Duma passed aother law baig advertisig, 13 proposed by the State Ati-Moopoly Committee, which prohibits advertisig o televisio betwee 7 am ad 10 pm. Advertisemets should carry a health warig, as should domestic, but ot imported, cigarette packs. Eve though this is a somewhat weaker policy tha a earlier proposal that year by the miistry of health ad medicie, it too is ot eforced. I practice, there is very widespread promotioal activity by wester tobacco compaies, with extesive use of images that idetify smokig with a glamorous wester lifestyle. 14 Sice 1991, tobacco prices have bee icreasig ad, sice 1994, excise taxes were itroduced, as were steep import duties o cigarettes, but ot o uprepared tobacco. 13 The actual cosequeces of these actios, give the evidece of extesive smugglig, are ot well clear. The extet of peetratio of the trasatioal tobacco idustry ito cetral ad easter Europe ad the former Soviet Uio is clearly of great importace ad has recetly bee reviewed by Coolly. 12 Cosumptio of cigarettes produced by wester compaies has accelerated rapidly i Russia, aided by the ear collapse of the local productio capacity i 1990 due to a breakdow of distributio etworks ad spare parts. Wester compaies rapidly took advatage of this situatio with RJ Reyolds, Philip Morris, ad British America Tobacco providig a emergecy supply estimated at 38 billio cigarettes. 15 This has bee reported as causig a 72-fold icrease i imports of America cigarettes i the first six moths of Sice 1991, wester ivestmet i the tobacco idustry has bee, at the very least, $310 millio, 12 makig this the largest wester ivestmet i ay sector i Russia. As the profits accruig to tobacco compaies i the former Soviet Uio are very much less tha i other parts of the world ($2.29 per thousad cigarettes compared with $15.82 per thousad i the USA ad $6.03 i the Europea Uio), 17 it will be ecessary for the idustry to icrease sales cosiderably, simply to recoup their ivestmets. 12 I summary, smokig is very prevalet amog youg ad middle-aged me i Russia ad, for this group, is iflueced little by geography. It has historically bee much less commo amog wome ad remais so i the more traditioal areas of Russia, although it is icreasig rapidly amog youger wome ad especially those i areas exposed to greater wester ifluece. There has bee a log-term upward tred i deaths from lug cacer amog me to what are ow extremely high levels by iteratioal stadards. The log-term upward tred i deaths from lug cacer amog wome has so far bee more gradual, but the evidece of a recet icrease i smokig amog youger wome is likely to feed through to much higher mortality rates i the future. The New Russia Barometer Survey is udertake by the Cetre for the Study of Public Policy, Uiversity of Strathclyde. This work was udertake as a subsidiary study to a major piece of work o adult mortality i Russia fuded by a grat from the UK Departmet for Iteratioal Developmet. However, DfID ca ot accept ay resposibility for ay iformatio provided or views expressed. 1 Perlez J. Cigarette maker s smokey have: Easter Europe. Iteratioal Herald Tribue 1997 Ju 25:2. 2 Peto R, Lopez AD, Boreham J, et al. Mortality from smokig i developed coutries Oxford: Oxford Uiversity Press, Rose R. New Russia Barometer VI: after the presidetial electio. Studies i public policy No 272. Glasgow: Uiversity of Strathclyde, The Russia Logitudial Moitorig Survey. < 5 Puska P, Matilaie T, Jousilahti P, et al. Cardiovascular risk factors i the Republic of Karelia, Russia, ad i North Karelia, Filad. It J Epidemiol 1993;22: The priciple ivestigators. The MONICA Project: a worldwide moitorig system for cardiovascular disease. I: WHO: world health statistics aual. Geeva: World Health Orgaizatio, 1989: Piha T, Besselik E, Lopez AD. Tobacco or health. World Health Stat Q 1993;46: El garov AA, El garova LV. Otosheie shkol ikov Nal chika k vredym privychkam. Ter-Arkh 1994;66: Prokhorov AV, Alexadrov AA. Tobacco smokig i Moscow school studets. Br J Addict 1992;87: Tob Cotrol: first published as /tc o 1 March Dowloaded from o 2 July 2018 by guest. Protected by copyright.

5 26 McKee, Bobak, Rose, et al 10 El garov AA, Zhasmiova VG, Kostatiov VV, et al. Chastota ishemicheskoi bolezi serdtsa i faktorov ee riska u muzhchi let-rabotikov fizicheskogo i umstveogo truda. Ter-Arkh 1992;64: Prokhorov AV. Gettig o Smoki Route 66: tobacco promotio via Russia mass media. Tobacco Cotrol 1997; 6: a Cheet L, Leo D, McKee M, et al. Death from alcohol ad violece i Moscow: Socio-ecoomic determiats. Eur J Populatio (I press) 12 Ao. Tobacco or health: first global status report. Geeva: World Health Orgaisatio, 1996:EUR-78 EUR Hurt RD. Smoki Russia: what do Stali ad wester tobacco compaies have i commo? Mayo Cli Proc 1995;70: Prokhorov AV. Smokig i Russia. Copehage: World Health Orgaisatio Europea Regioal OYce, Ao. The pushers are comig! The pushers are comig!... ToRussia. Tobacco Cotrol It 1992;1:9. 16 Coolly GN. Tobacco, trade ad easter Europe. I: Slama K, ed. Tobacco ad health. Lodo: Pleum Press, 1996: Steveso RW. Tappig a rich smokig frotier. New York Times 1993 Nov 12:D1. Tob Cotrol: first published as /tc o 1 March Dowloaded from o 2 July 2018 by guest. Protected by copyright.