Children

1
Childrens Exposure to Environmental Smoke /
Involuntary Smoking in Developing Countries
Current Situation and Implications for Health and
Development

• Enis Baris
• and
• Ayda A. Yürekli
• World Bank,
• Washington, D.C.

2
Outline

• Overview
• Health effects
• Determinants of ETS
• Review of evidence on determinants from
  developing countries
• Estimation of exposure to ETS by level of income
  and regions
• Recommendations

3
Lack of Access to Clean Air and Child Health

• According to WHO, 700 million children around the
  world were exposed to second hand smoke in 1999.
  
• Lack of clean air is associated with
• lower respiratory tract infections
• middle ear disease
• chronic respiratory symptoms
• asthma
• decreased lung function
• sudden infant death syndrome (SIDS).

Source WHO/TFI International Consultation on
ETS and Child Health, 1999
4
Determinants of ETS Exposure

• The intensity of exposure
• The number of smokers
• The extent of cigarette consumption
• The behavior of smokers
• Legislation that restricts smoking in public and
  work places and its enforcement.

5
In Developing Countries

• Same negative health effects
• But of different magnitude
• due to variation in the relative importance of
  exposure determinants, mostly
• smoking behavior
• legislation
• prevailing social norms and ecology, and
• as a result of different health and socioeconomic
  impact in terms of
• health consequences (nutrition, co-morbidity)
• healthcare costs
• absenteeism
• societal response (tolerance, compliance,
  complacency, etc)

6
Intensity of ExposureNumber of smokers around
the globe 2000
Prevalence rate in selected developing countries
1.2 billion smokers globally 83 of global
smokers (956 million) live in developing
countries
Prevalence rate (in 90s) Male Female
Bangladesh 40 10
Turkey 59 26
Vietnam 73 4
Pakistan 36 9
China 63 4
Indonesia 63 2
Russia 63 14
Philippines 75 18
Egypt 43 5
7
Intensity of ExposureGlobal Cigarette
Consumption 2000In 2000, 6.2 Trillion Cigarettes
Smoked Worldwide.Developing Countries Smoked 74
of Global Cigarette Consumption (4.6 Trillion
Cigarettes)
Global cigarette consumption 6260
billion pieces
Consumption (mil. pieces) global share
LI 1295 21
LMI 2733 43
UMI 613 10
HI 1619 26
Total 6260 100
China 1688 27
India 947 15
LI w/o India 348 6
LMI w/o China 1045 17
8
Intensity of ExposureDaily Smoke
Daily 11 to 21 sticks smoked by smokers
9
Smokers smoking behavior Evidence from
Indonesia 1995

• National Health Survey 1995
• of Total HH 31,126,882
• of HH member 109,154,973
• of smoker 38,652,636
• of smoker smoke
• at home 36,888,636
• Average
• HH member 3.51
• Smoker per HH 1.24
• Smoker smoke at home 1.18
• of cigarettes smoked/day 11 pieces

• Estimated ETS Exposure
• of smokers smoke at home 95.4
• Average non-smoker per household 2.26
• of HH members exposed to ETS 65

Source Authors estimate based on National
Health Survey data, 1995
10
Smokers smoking behaviorEvidence from Turkey
Source Bilir, N et al. 1997. Smoking behavior
and attitudes, Ankara, Turkey
11
High ETS Exposure Among 13-15 Year Olds in
Selected Low and Low-middle Income Countries
children exposed children exposed children exposed children exposed
LMI At home At public places At home At public places
Indonesia 69 84 China 54 51
Philippines 58 75 India 59 67
Jordan 67 61 Nepal 36 47
Russia 55 73 Nigeria 34 50
Bolivia 46 62 Sri Lanka 56 68
Venezuela 44 48 Ukraine 49 72
Uruguay 64 79 Zimbabwe 35 58
Source GYTS Survey Data, 1999-00-01
12
Smoking restrictions in various places
Countries HC Facilities Education Facilities Buses Waiting areas Entertainment centers Shopping centers
China B B B B B B
Philippines N N N N N N
Thailand B D B D B B
Iran B B B B B B
Turkey D D D D D D
Poland D D N D D D
Indonesia B B D N N N
Nigeria B B B N N N
Malaysia B B B B B B

B banned, N None, D Designated areas
13
Source of Data

• Nations Prevalence rates
• USDA Cigarette consumption
• WBI Children and adult population
• GYTS ETS exposure among 13-15 y of age

14
Percentage of 1.8 billion children aged 0-14
years living in developing countries, 2000
0-14 yrs old population (mil) share in total pop. share in global child population
Low Income 842 37 47
Low Middle Income 628 27 35
Upper Middle Income 172 29 10
High Income 162 18 9
LI and LMI 1,471 32 82
All Developing 1,642 33 91
Developed 162 18 9
Total 1,805 31 100
Source WBI and Authors calculation
15
Children (0-14 years old ) and ETS exposure
Selected countries with the highest child
population and ETS exposure, 2000
Total (0-14 age) child pop. (Million) share in global 0-14 age child population of ETS Exposure 13-15 years old students Home Public Places of ETS Exposure 13-15 years old students Home Public Places
India 340 18.9 59 67
China 314 17.4 54 51
Indonesia 65 3.6 9 84
Pakistan 58 3.2 N/A N/A
Nigeria 57 3.2 34 50
Philippines 28 2.6 58 75
Vietnam 26 1.5 N/a N/a
Russia 26 1.4 55 73
Total 994 55 N/A N/A
16
Top 10 countries w/highest child population and
ETS exposure
0-14 age population share in global 0-14 age of 13-15 age exposed to ETS Home Public of 13-15 age exposed to ETS Home Public
India 340 18.9 59 67
China 313 17.4 54 51
Indonesia 65 3.6 69 84
Pakistan 58 3.2 N/A N/A
Nigeria 57 3.2 34 50
Bangladesh 51 2.8 N/A N/A
Ethiopia 29 2.6 N/A N/A
Philippines 28 2.6 58 75
Vietnam 26 1.5 N/A N/A
Russia 26 1.4 55 73
Total 0-14 pop.(top 10) 944 55.0
Global 0-14 pop. 1805
Source WBI GYTS
17
Over 900 million children living in developing
world were exposed to ETS in 2000.
Source World Bank Estimation
18
Percentage of children 0-14y of age exposed to
ETS at home in developing countries, 2000
Income Groups of exposed children at home in developing world (million) share within income group share in developing world share globally
LI 380 48 23 21
LMI 371 55 22 20
UMI 84 44 5 4
Total 837 46
Source Authors calculation
19
Percentage of children 0-14y of age exposed to
ETS in public places in developing countries,
2000
Income Groups of exposed children in public places in developing world (million) share within income group share in developing world share globally
LI 461 59 28 26
LMI 365 53 21 20
UMI 99 57 7 6
Total 925 51
Authors calculation
20
Top 10 UMI countries with the highest number of
children exposed to ETS at home and public places
Region Country of children exposed to ETS at home (mil) of children exposed to ETS in public places (mil)
LAC Brazil 25 32
LAC Mexico 17 21
ECA Turkey 12 11
AFRICA S. Africa 6 8
LAC Argentina 5 7
EAP Korea Rep. 5 6
ECA Poland 5 5
MENA S. Arabia 5 6
LAC Venezuela 4 5
EAP Malaysia 4 5
21
Top 10 LMI countries with the highest number of
children exposed to ETS at home and public places
Region Country of children exposed to ETS at home (mil) of children exposed to ETS in public places (mil)
EAP China 171.0 166.0
EAP Indonesia 35.2 34.2
SA Pakistan 32.2 21.9
MENA Iran 16.0 14.6
EAP Philippines 15.4 15.0
MENA Egypt 15.2 13.9
ECA Russia 14.4 18.9
EAP Thailand 8.8 8.6
MENA Morocco 6.7 6.1
MENA Iraq 6.5 5.9
22
Top 10 LI countries with the highest number of
children exposed to ETS at home and public places
Region Country of children exposed to ETS at home (mil) of children exposed to ETS in public places (mil)
SA India 199.0 227.8
SA Bangladesh 29.7 34.0
AFRICA Nigeria 18.4 27.6
EAP Vietnam 14.0 13.3
AFRICA Ethiopia 9.3 14.0
EAP Myanmar 8.5 8.1
AFRICA Congo Dem.Rep. 8.0 12.0
SA Afghanistan 6.8 7.7
MENA Yemen 5.9 3.6
SA Nepal 5.5 6.3
23
Results

• 91 of global children aged 0-14 years live in
  developing world.
• 83 of global smokers (956 million) live in
  developing countries.
• In 2000, developing countries smoked 74 of
  global cigarette consumption (4.6 trillion
  cigarettes).
• Lower number of cigarettes smoked per capita.
• Still high rate of ETS exposure at homes and
  public places
• Over 800 million children are exposed to ETS at
  homes and 900 million in public places in
  developing countries.
• Most smokers still smoke near non-smokers and/or
  in front of children.

24
Conclusion Worrisome Trends and Patterns

• Exposure of children to ETS is larger than
  previously estimated
• Exposure is equally significant in homes and
  public places, although this varies depending on
  legislation and social norms
• Exposure is likely to become more significant as
• Women take up smoking
• Countries develop and economies grow
• Exposure is likely to be more hazardous due to
  other factors, e.g. poverty, other indoor
  pollutants, nutritional deficiencies, etc.

25
Conclusion Policy Implications

• Implementation of Framework Convention on Tobacco
  Control, including legislative initiatives
  inclusive of ETS
• Higher taxes, especially where price elasticity
  is higher and
• Involvement of professional associations
  (teachers, doctors, police force), womens
  groups, athletes, etc to mobilize social elites
  to challenge and change prevailing social norms
  and enforce existing laws and ordinances.
• More comprehensive public health action, bundled
  with IAP and other initiatives.

26
Conclusion Research Implications

• There is a need to
• Identify culture-specific determinants of ETS
  amenable to interventions, including risk
  perception and communication
• Pilot innovative programs involving role models
  (teachers, mothers, athletes, etc.) and targeting
  home environments
• Estimate ETS attributable burden of disease and
  health care costs in developing countries
• Document and cost non-health related effects of
  ETS, e.g. absenteeism from school, work, etc and
• Seek synergism with other development issues such
  as IAP due to coal, biomass use, etc.