The Extent of the Tobacco Epidemic

Smoking prevalence among adult males in the NIS has been estimated to range from 27 percent in Turkmenistan to 67 percent in the Russian Federation, and among adult females from 1 percent in Turkmenistan and Uzbekistan to 20 percent in Estonia (Piha et al., 1993; Tkachenko and Ryazantsev, 1993). Among the adult male population of the Russian Federation, estimated smoking prevalence increased from 53 percent in 1985 to 67 percent in 1992 (Tkachenko and Ryazantsev, 1993). In the period 1990-1993, the highest estimated per adult yearly consumption of cigarettes was in Armenia (3,000) and Turkmenistan (2,400), followed by Moldova, Georgia, and Ukraine. The lowest consumption was in Uzbekistan (less than 1,000). In most of the NIS countries, including the largest (the Russian Federation and Ukraine), the estimated per adult consumption of cigarettes was between 1,500 and 2,000. These per capita cigarette consumption figures are very rough estimates calculated from data on production, imports, and exports (Lopez, personal communication, 1995). Nevertheless, they are sufficiently reliable to suggest the extent of the tobacco epidemic across the NIS.

Adolescent smoking is a matter of special concern. According to the Ministry of Health and Medical Industry of Russia (1994), there are about 2.5 million adolescent smokers aged 15-17 in Russia. It is an alarming fact that the smoking rates among youngsters are growing. Increases are especially apparent among girls, rising from approximately 12 percent in 1986 to 20 percent in 1993 (Alexandrov et al., no date). A recent large-scale study of over 36,000 senior high school students (aged 15-17) residing in urban areas of the Russian Federation has revealed that smoking rates vary substantially, from 25 to 26 percent in the areas of Kirov and Tver, to 43 to 48 percent in Moscow and Irkutsk (Komarov and Skvortsova, no date). Among males, the average smoking prevalence is 36 percent; daily tobacco users represent the vast majority of smokers. Among senior high school female students, the average smoking prevalence is 17 percent. It may be expected that the popularity of smoking among children and adolescents will increase immensely with the breakthrough of the Western tobacco industry into the markets of the NIS.

Spread of Western Tobacco Products

Before the 1990s, Western tobacco products rarely appeared in the former Soviet market. They were practically unknown across the entire vast Soviet territory, except for big cities such as Moscow and Kiev and major seaports such as Odessa and Tallinn. At that time, the vast majority of tobacco products in the NIS consisted of domestically manufactured filter-tipped and plain cigarettes, as well as papirossi (unfiltered tobacco products with a 1 to 1.5 inch-long tobacco-filled portion and a paper holder). Only about 30 percent of the latter tobacco products were filter-tipped (Heseltine et al., 1987).

However, in the period 1991 to 1993, as shown in Figure 10-1, the importation of both raw tobacco and cigarettes to Russia almost quadrupled and reached unprecedented levels. Along with this increasing importation of tobacco products, the transnational tobacco companies have been actively engaging in joint ventures with former Soviet tobacco factories or buying the bankrupt and disabled cigarette-manufacturing facilities.

Figure 10-1

Importation of tobacco leaf and cigarettes, Russia, 1986-1993. Source: Report of the Ministry of Health and Medical Industry of Russia.

The first such company to make a business agreement in Russia was the American Liggett Group, which formed a partnership in 1991 with the Moscow Dukat Tobacco factory after the well-known 1989-1990 crisis in the Russian domestic tobacco industry resulted in severe tobacco shortages. As a result, a brand-new cigarette factory with a planned capacity of 35 billion cigarettes per year, the largest in Russia, was opened in 1993 (European Bureau for Action on Smoking Prevention, 1993). In 1992, Philip Morris, which already has a joint venture with a cigarette factory in Samara (in the European part of Russia), announced plans to build a new factory in Viborg, north of St. Petersburg and adjacent to the border with Finland. It is understood that the new plant will produce 10 billion cigarettes per year (Ridgway, 1992). Developments in other NIS countries are not far behind. In Ukraine, for example, the four largest cigarette production factories were bought by Reemtsma, BAT, and RJ Reynolds, and these four cover 60 percent of the Ukrainian tobacco market (Naett, 1994). Thus, the ''westernization" of the cigarette markets in the NIS, characterized by an increasing market share of Western-type cigarettes, tobacco promotion, and advertising, is in progress.

Health Consequences

The tobacco and health situation today in most of the NIS countries can be characterized as dangerous. As shown by Lopez (in this volume), excess mortality due to smoking among the populations of the NIS (especially middle-aged males) is quite substantial. Some states, such as Kazakstan, Russia, the Baltic States, and Armenia, are experiencing a more extreme problem than others. For example, in Kazakstan, nearly half of deaths from all causes among males and over one-tenth of such deaths among females are attributable to tobacco use. There has also been a substantial increase in major tobacco-attributable diseases in the NIS. For example, the proportion of cancer deaths among overall male mortality in Russia increased from 16.2 percent in 1970 to 18.2 percent in 1988; the proportion of cardiovascular deaths increased from 46 to 52.5 percent within the same period (World Health Organization, 1992). Therefore, there is some urgency to the initiation of anti-smoking measures in the NIS.

The health consequences of smoking in the NIS may be even more devastating than elsewhere because of the higher carcinogenicity of the domestically manufactured tobacco products that have been available in the markets of these countries over the last several decades, as compared with the tobacco products manufactured in the United States and Western Europe. As noted above, Western tobacco products appeared in the markets of the NIS just recently, and they are still not affordable to a majority of smokers in those states. The domestic cigarettes that are the most commonly used tobacco products feature exceptionally high tar yields. Table 10-1 shows the tar, nicotine, and carbon monoxide content of selected brands of cigarettes manufactured in the NIS.

TABLE 10-1

Content of Noxious Substances in Selected Cigarettes Manufactured in the New Independent States.

It is also important to consider that although the American and Western European cigarettes sold in the NIS carry the same brand names as those sold in the West, as a rule they do not meet Western standards in terms of the content of noxious substances. Table 10-2 shows the results of a study conducted by researchers from the Research Institute of Carcinogenesis that illustrate this substantial difference. Overall, the tobacco products available in the markets of the NIS have never met the noxious substance yield standards introduced in most Western countries. It is important to note that even though the content of noxious substances in the domestic brands is significantly higher, switching from domestic to Western brands is unlikely to yield much health benefit. It has been demonstrated that as a rule, such a switch results in a compensatory increase in the number of cigarettes smoked and deeper inhalation (U.S. Department of Health and Human Services, 1981).

TABLE 10-2

Comparative Data on Tar, Nicotine, and Carbon Monoxide (CO) Yields (mg/cigarette) in Brands of Cigarettes Sold in Both Russia and the United States, May 1993.

Considering the potentially higher dose-response effect of tobacco products manufactured and imported in the NIS, one might conclude that tobacco-related mortality in these states (particularly from cancer), calculated on the basis of relative risk measured in the United States, is greatly underestimated.

Curbing the Spread of the Epidemic

Without some obstacles to the penetration of the transnational tobacco companies into the markets of the NIS, there is likely to be a major increase in tobacco use in the region over the next few years, leading to an increase in smoking-related diseases and deaths.

Tobacco advertising is one of the most important factors contributing to such a major increase in tobacco use (see Pierce, in this volume). The impact of tobacco advertising on the populations of the NIS, especially the younger generations, will be even stronger than would be expected in Western countries. This is because most of the NIS countries have been isolated and virtually unexposed to Western-type advertising for decades; the exception is the Baltic states, which have had greater access to Western European cultures. Using medical terminology, these states have not been "immunized" against tobacco advertising; therefore, they are particularly sensitive to it.

Another important issue is that throughout the Soviet era, Western-manufactured cigarettes not only were more socially acceptable than Soviet-made tobacco products, but also were highly attractive because, in a sense, they symbolized a desirable Western lifestyle. Now these products are widely available, and they are rapidly gaining popularity. The tobacco industry aggressively promotes the perceived "wealthy lifestyle with Western cigarettes" among youth by advertising and sponsoring popular events in ways that are familiar to all in the West. Most recently, ads in 1994 offered a lottery with a grand prize of a new sports utility vehicle (shown with three young adults clearly enjoying themselves), decorated with the cigarette company logo.

Measures to curb the further spread of tobacco advertising are urgently needed. These measures should take into account the extensive experience gained over the years in the West and the success of Western anti-smoking programs (see Pierce, in this volume). At the same time, they should also be specific to the region. It is important to remember that in terms of social norms and public awareness of smoking hazards, the NIS countries differ a great deal from Western countries.

Readiness to Implement the Priorities

Implementation of the priorities listed in Table 10-3 in the near future is crucial for successful tobacco control in the NIS. However, government officials and the public need to reach a certain level of commitment to achieving these goals in order to bring about change in the smoking situation in their countries. Unfortunately, the republics of the former Soviet Union have a long and quite disappointing history of procrastinating when it comes to tobacco control programs. Over decades of Soviet history, numerous anti-smoking propaganda campaigns were declared by the Central Committee of the Communist Party and by the government, but were never properly executed at the local level. Many of them were short-lived or poorly carried out. Perhaps in the future, a less declarative approach should be used, and an effective means of changing public perception of the severity of the tobacco and health problem should be identified.

In essence, borrowing from the transtheoretical model of change (Prochaska and DiClemente, 1982),¹ the vast majority of the governments and populations of the NIS are still in the precontemplation stage of change with regard to smoking. In other words, the societies do not yet intend to invest heavily in antismoking measures, at least in the foreseeable future. It would be as wasteful to try to implement action-oriented national anti-smoking campaigns in these contexts as to prescribe nicotine replacement agents for smokers who are not intending to quit. Similar to many smoking individuals in the precontemplation stage, the societies of the NIS seem to be preoccupied with other problems that require urgent solutions, including the critical state of their economies and increasing crime rates. Yet this does not mean one should simply wait until the countries of the NIS reach a desirable level of readiness to control smoking. The transtheoretical model of change suggests appropriate activities that individuals at each stage can use to accelerate their progress toward healthier behavior. One of the activities suggested for early stages is consciousness raising, that is, increasing information about self and the problem. Thus, again extrapolating the model to the societal level, efforts should be concentrated on this very issue-the raising of public awareness about the devastating consequences of smoking for the nation's health and economy.

Top Priority: Raising Awareness

The tobacco situation in the NIS today is similar to that in the United States preceding the release of the first Report of the Surgeon General in 1964. Cigarette smoking rates are high, smoking is socially acceptable throughout the countries of the region, and there is no serious governmental effort to reduce the smoking epidemic. To a large degree, this situation is caused by a lack of awareness and, as a result, an underestimation of the devastating health consequences of tobacco use.

There have been attempts to raise public awareness about tobacco hazards in Russia, Belarus, and other republics of the former Soviet Union (Shevchuk et al., 1991; Shevchuk, 1987). However, these sporadic, local anti-tobacco campaigns did not provide locally salient information on smoking and health issues. In the absence of any national reports on tobacco and health, evidence from Western countries was used. Not surprisingly, that approach typically had little or no impact.

To increase public awareness of tobacco and health issues and launch a broad anti-tobacco campaign in the NIS, one has to answer two basic questions:

• What type of information will be meaningful and appealing to both governments and the general public?
• Who should be mobilized to get this message across?

These two questions are addressed below.