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Smoking and Poverty
Interaction with TB in the Developing World




                       Donald A Enarson
            The Union Asia Pacific Region
                             9 July 2011
Learning Objectives
By the end of the session you will be able to:

  Confirm the association of tobacco and TB;
  Outline the feasibility of smoking cessation
  for TB patients;
  Describe the plague of tobacco smoking and
  its toll;
  Explain how this impacts on health and
  economics;
  Identify the new directions of tobacco
  marketing.
Association of TB and Smoking

 Disease and Active Smoking;
   Sub-Saharan Africa
   Western Pacific
   Southeast Asia
   Latin America
 Disease and Passive Smoking;
   Southeast Asia.
Smoking Cessation for TB patients
 Smoking cessation services are feasible and
 do not negatively affect TB care:
   El Sony A, Slama K, Slieh M, Elhaj H, Adam K, Hassan A,
   Enarson DA. Feasibility of brief tobacco cessation advice for
   tuberculosis patients: a study from Sudan. Int J Tuberc Lung
   Dis 2007; 11: 150-155

 There is a practical approach to smoking
 cessation for low-income countries
   Slama K, Chiang C-Y, Enarson DA. Tobacco Cessation
   Interventions for Tuberculosis Patients. A Guide for Low-
   Income Countries. Paris: International Union Against
   Tuberculoisis and Lung Disease. 2008, pp 57. ISBN 978-2-
   914365-31-4
Association of TB and Poverty
                           100000
                                    Norway
         G NI per capita



                                        Sweden
                           10000             Poland
                                                            Thailand
                                                      Romania
                            1000                                          Indonesia

                                                         Pakistan

                             100
                                    1            10                 100               1000
                                        Estimated cases per 100,000 - 2002


WHO Global TB Report
Information on Smoking

 http://www.tobaccoatlas.org
Prevalence of Smoking by Country
Proportion of Men who Smoke
       60+       40-59         20-39         <20
 Afghanistan     China         France     Sweden

     Yemen       Turkey   New Zealand     Canada
      Russia   Malaysia          India     Zambia
    Ukraine     Austria        Ireland    Senegal
     Belarus   Mongolia   South Africa   RD Congo
  Indonesia       Chile         Egypt      Nigeria
               Portugal         Brazil    Ethiopia
Smoking by Country
Fraction of Women to Men who Smoke


Afghanistan .21     China .06         France .73    Sweden 1.25

    Yemen .38      Turkey .37 New Zealand .93        Canada .92
     Russia .38 Malaysia .05           India .04     Zambia .12
   Ukraine .36     Austria .86       Ireland .98    Senegal .04
    Belarus .33 Mongolia .14     South Africa .31 RD Congo .06
 Indonesia .06       Chile .72        Egypt .04      Nigeria .02
                  Portugal .76         Brazil .63   Ethiopia .07
Burden to Health from Smoking
Proportion of Deaths in Men from Tobacco

        <10          10-19       20+
        India   Afghanistan   Belarus    New Zealand
     Ethiopia        Brazil    Austria       Ukraine
   RD Congo           Chile   Sweden          Turkey
     Zambia        Malaysia    France
 South Africa    Indonesia     Russia
                     China    Canada
                     Egypt    Portugal
                    Yemen      Ireland
Burden to the Individual Economy
       Cost of a Pack per $1,000 GNI

   Ethiopia
  RD Congo
      India
     China
  Indonesia
   Malaysia
New Zealand
    Canada
     Russia
    Sweden


              0   1           2          3            4   5
                      Cost of a Pack per $1,000 GNI
Costs to the General Economy
        Total Estimated Costs

    Sweden

  Indonesia

South Africa

      Egypt

      China

     France

    Canada


               0    5000         10000        15000     20000
                   Total Estimated Costs ($ millions)
Existing Market for Tobacco
 Ukraine men

Russia women

  Turkey men

   Brazil men

China women

  Russia men

Indonesia men

    India men

   China men


                0   100     200       300       400   500
                          Millions of Smokers
Future Market for Tobacco
  Russia women
    Nigeria men
      Brazil men
  Nigeria women
   Brazil women
Indonesia women
     China men
      India men
    India women
   China women


                   0   100     200    300    400    500      600   700
                             Millions of Potential Smokers
Effect of Cost on Smoking
Excluding Industrialized Countries

                             10
Cost of a Pack per $1,000




                              1
           GNI




                             0.1


                            0.01
                                   0   20      40       60       80   100
                                            % of Men who Smoke
Smoking and Poverty
Key points

  Tobacco smoking is facilitated by
  ‘relative’ wealth;
  It can be a burden to both health
  and wealth;
  Future markets for tobacco will
  target women and selected
  developing countries.
TB, Smoking and Poverty
Key points

  Tobacco control is important
  everywhere;
  It should be a priority for TB
  patients;
  It is feasible;
  The highest dual burden is in
  middle-income countries.

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27.smoking and poverty,their interaction with tuberculosis in the developing world

  • 1. Smoking and Poverty Interaction with TB in the Developing World Donald A Enarson The Union Asia Pacific Region 9 July 2011
  • 2. Learning Objectives By the end of the session you will be able to: Confirm the association of tobacco and TB; Outline the feasibility of smoking cessation for TB patients; Describe the plague of tobacco smoking and its toll; Explain how this impacts on health and economics; Identify the new directions of tobacco marketing.
  • 3. Association of TB and Smoking Disease and Active Smoking; Sub-Saharan Africa Western Pacific Southeast Asia Latin America Disease and Passive Smoking; Southeast Asia.
  • 4. Smoking Cessation for TB patients Smoking cessation services are feasible and do not negatively affect TB care: El Sony A, Slama K, Slieh M, Elhaj H, Adam K, Hassan A, Enarson DA. Feasibility of brief tobacco cessation advice for tuberculosis patients: a study from Sudan. Int J Tuberc Lung Dis 2007; 11: 150-155 There is a practical approach to smoking cessation for low-income countries Slama K, Chiang C-Y, Enarson DA. Tobacco Cessation Interventions for Tuberculosis Patients. A Guide for Low- Income Countries. Paris: International Union Against Tuberculoisis and Lung Disease. 2008, pp 57. ISBN 978-2- 914365-31-4
  • 5. Association of TB and Poverty 100000 Norway G NI per capita Sweden 10000 Poland Thailand Romania 1000 Indonesia Pakistan 100 1 10 100 1000 Estimated cases per 100,000 - 2002 WHO Global TB Report
  • 6. Information on Smoking http://www.tobaccoatlas.org
  • 7. Prevalence of Smoking by Country Proportion of Men who Smoke 60+ 40-59 20-39 <20 Afghanistan China France Sweden Yemen Turkey New Zealand Canada Russia Malaysia India Zambia Ukraine Austria Ireland Senegal Belarus Mongolia South Africa RD Congo Indonesia Chile Egypt Nigeria Portugal Brazil Ethiopia
  • 8. Smoking by Country Fraction of Women to Men who Smoke Afghanistan .21 China .06 France .73 Sweden 1.25 Yemen .38 Turkey .37 New Zealand .93 Canada .92 Russia .38 Malaysia .05 India .04 Zambia .12 Ukraine .36 Austria .86 Ireland .98 Senegal .04 Belarus .33 Mongolia .14 South Africa .31 RD Congo .06 Indonesia .06 Chile .72 Egypt .04 Nigeria .02 Portugal .76 Brazil .63 Ethiopia .07
  • 9. Burden to Health from Smoking Proportion of Deaths in Men from Tobacco <10 10-19 20+ India Afghanistan Belarus New Zealand Ethiopia Brazil Austria Ukraine RD Congo Chile Sweden Turkey Zambia Malaysia France South Africa Indonesia Russia China Canada Egypt Portugal Yemen Ireland
  • 10. Burden to the Individual Economy Cost of a Pack per $1,000 GNI Ethiopia RD Congo India China Indonesia Malaysia New Zealand Canada Russia Sweden 0 1 2 3 4 5 Cost of a Pack per $1,000 GNI
  • 11. Costs to the General Economy Total Estimated Costs Sweden Indonesia South Africa Egypt China France Canada 0 5000 10000 15000 20000 Total Estimated Costs ($ millions)
  • 12. Existing Market for Tobacco Ukraine men Russia women Turkey men Brazil men China women Russia men Indonesia men India men China men 0 100 200 300 400 500 Millions of Smokers
  • 13. Future Market for Tobacco Russia women Nigeria men Brazil men Nigeria women Brazil women Indonesia women China men India men India women China women 0 100 200 300 400 500 600 700 Millions of Potential Smokers
  • 14. Effect of Cost on Smoking Excluding Industrialized Countries 10 Cost of a Pack per $1,000 1 GNI 0.1 0.01 0 20 40 60 80 100 % of Men who Smoke
  • 15. Smoking and Poverty Key points Tobacco smoking is facilitated by ‘relative’ wealth; It can be a burden to both health and wealth; Future markets for tobacco will target women and selected developing countries.
  • 16. TB, Smoking and Poverty Key points Tobacco control is important everywhere; It should be a priority for TB patients; It is feasible; The highest dual burden is in middle-income countries.