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Historical Context 55 Chapter 3 Prevalence and Mortality Preface 59 Prevalence of Smoking in Latin America and the Caribbean 61 Introduction 61 Demographic Characteristics 62 Population Configuration 61 Urbanization 62 Educational Opportunities 63 Income Distribution and the Labor Force 64 Prevalence Estimates 65 Prevalence Reported by the Pan American Health Organization 66 Prevalence Reported by the Gallup Organization 67 Prevalence Reported by Reproductive Health Surveys 68 Additional Prevalence Estimates Reported Since 1980 70 Smoking-Attributable Mortality in Latin America and the Caribbean 81 Introduction 81 Mortality Data 81 Coverage 81 Data Quality 82 Coding 83 Life Expectancy and Mortality 83 Trends in Life Expectancy and Overall Mortality 83 Estimates of Mortality 84 Total, Cause-Specific, and Age-Specific Mortality 8.5 Mortality from Smoking-Related Diseases 86 Estimates of Cause-Specific Mortality 86 Estimates of Relative Risk Due to Smoking 87 Smoking-Attributable Mortality 89 Estimates of Smoking-Attributable Mortality Worldwide 89 Lung Cancer Mortality as an Index of Prior Smoking in a Population 89 Estimates of Smoking-Attributable Mortality in the Americas 91 Unadjusted Estimates 91 Adjusted Estimates 92 A Comment on the Methodology 93 Conclusions 97 References 98 Preface In any population, the prevalence of smoking and the demonstrable health effects of tobacco consumption are out of phase. For some diseases, such as lung cancer, the lag may be 20 years or more; for heart disease or adverse outcomes of pregnancy, the lag may be considerably shorter. But the overall burden of disease reflects the cumulatizle long-term impact of tobacco use, or "maturity" of the smoking epidemic. This relationship betzrleen prevalence of smoking and smoking-related disease has been examined in detail for North America and zoill not be reiterated here. Rather, thefocus is on the countries ofthe Americas in which tobacco use is an emerging problem. This discussion juxtaposes estimates of the current prevalence of smoking in Latin America and the Caribbean zuith estimates of smoking-attributable mortality. Both esti- mates attempt to define the dimensions of the current and future health threat posed by tobacco use in the region. Prez~alence and Mortality 59 Prevalence of Smoking in Latin America and the Caribbean Introduction The expansion of transnational corporations into international markets (described in Chapter 2) began in the early 195Os, accelerated in the 196Os, and was characterized by denationalization of local tobacco industries and development of consumer preference for the products of these corporations. In Latin Amer- ica and the Caribbean, these events occurred along with complex social and demographic changes-often characterized as a demographic transition (Omran 1971; Jamison and Mosley 19911--that made the area an attractive market for tobacco. These changes were not uniform throughout the region nor even, in some instances, uniform within a single country. Nonetheless, four main sociodemographic fac- tors have contributed to the potential of the popula- tion in Latin America and the Caribbean to initiate cigarette smoking. These factors are growth of groups likely to smoke, dissemination of an urban lifestyle, greater access to education, and the entry of women into the labor force. These factors are summarized below and related to available data on the prevalence of smoking. Demographic Characteristics Population Configuration The population size and growth rate in Latin America and the Caribbean have been affected pri- marily by changes in the birthrate and death rate; with some regional exceptions, migration and emigration have been less important. Changes in fertility, natal- ity, and mortality have been dramatic (Table 1). In 1930, overall mortality was high in Latin America, and life expectancy was only 35 years, al- though in several countries, such as Argentina, Uru- guay, and Cuba, life expectancy was greater because an export-driven economy (Merrick 1986) had encour- aged environmental and sanitary improvements. Most Latin American countries, however, did not in- troduce widespread methods for control of endemic diseases until after World War II. Between 1950 and 1970, improved methods for the control of major in- fectious diseases of children and adults may have accounted for 30 percent of the increase in life expec- tancy (Palloni 1981). By the 196Os, life expectancy at birth for citizens of most Latin American and Caribbean Table 1. Demographic indicators, Latin America and the Caribbean,* 1950-1990 Indicator 1950-55+ 1955-60 1960-65 1965-70 1970-75 1975430 198&85 198590 Annual growth rate (%)$ 2.73 2.75 2.79 2.60 2.48 2.29 2.17 2.06 Crude birthrates 42.5 41.7 4 ..l 38.0 35.4 32.4 30.6 28.7 Crude mortality rate" 15.4 13.6 12.1 10.9 9.7 8.6 7.9 7.4 Total fertility rate' 5.87 5.90 5.96 5.53 4.99 4.36 3.93 3.55 Life expectancy at birth** 51.9 54.8 57.3 59.2 61.3 63.3 65.2 66.7 Infant mortality rate++ 126 112 100 91 81 70 61 54 Source: United Nations (1991). *Excludes Belize and Puerto Rico. %om July of the first year to July of the last year in each period. *otal increase in population during one year divided by mean population for the same period. _Number of births during one year divided by mean population for the same period; per 1,000 persons. `Number of deaths during one year divided by mean population for the same period; per 1,000 persons. IAverage number of children that would be born during the fertile period of each woman in a hypothetical cohort (in accordance **with the fertility rate by age for the cohort) who was not at risk for mortality before the end of the fertile period. Average number of years that would be lived by a newborn in a hypothetical cohort subject to the mortality schedule in effect at the time. tiNumber of deaths per year among children under one year of age divided by number of births during the same period; per 1,000 persons. Prevalence and Mortality 61 Table 2. Estimated population,* Latin America, the Caribbean, and the United States, 1950-1990 Region 1950 1960 1970 1980 1990 Latin America and the Caribbean Total 165.9 218.1 285.7 362.7 449.9 215 years of age 98.5 (59.4)+ 125.4 (57.5) 164.3 (57.5) 220.2 (60.7) 287.5 (63.9) United States Total 152.3 180.7 205.1 227.8 251.3 215 of years age 111.3 (73.1) 124.5 (68.9) 147.0 (71.7) 176.5 (77.5) 197.0 (78.4) Source: United Nations (1991). `In millions. ?ercentage of total population 215 years is given in parentheses. countries was about 60 years. But since advances were not uniform, less industrially developed countries, such as Bolivia, Haiti, and the Central American coun- tries (except for Costa Rica), reported a life expectancy at birth of less than 50 years. Nonetheless, for the region as a whole, overall crude mortality and infant mortality have declined by over 50 percent since 1950 (Table 1). Through the first half of the twentieth century, the birthrate increased in Latin America, except for the urban populations of some countries (such as Argen- tina and Uruguay) that experienced early economic improvements. After 1965, the birthrate in larger countries, such as Brazil, Mexico, and Colombia, began to decrease, and the region as a whole experi- enced declining fertility. Total fertility has diminished by 40 percent since 1960 (Table 1). As a result of these changes, the population growth rate for Latin America and the Caribbean in- creased between 1900 and 1940, peaked just after World War II, and leveled off at 2.8 percent per year from 1945 to 1965. Since then, the rate of growth has slowed; it is estimated at 2.1 percent from 1985 to 1990 (Table 1). In 1950, the total population of the region was only slightly greater than that of the United States, but by 1990, it was 1.8 times greater (Table 2). Al- though the proportion of the population in Latin America and the Caribbean under 15 years of age has remained high (from 41 percent in 1950 to 36 percent in 1990) compared with that of the United States (from 27 percent to 22 percent), the number of persons aged 15 or over (the main tobacco users) in Latin America and the Caribbean increased dramatically over that in the United States. In 1950, the population aged 15 or over in Latin America and the Caribbean was 13 per- cent smaller than that in the United States; in 1990, it was 32 percent larger. These population shifts have created a large po- tential market of tobacco consumers in Latin America. Further, the trend in the birthrate ensures that a sub- stantial number of young people will continue to enter the market for some time to come. Urbanization Although immigration and emigration have had local effects, they have not had a large effect on the demographic composition of the Latin American re- gion as a whole. However, internal migration has. Large-scale internal migration began in Latin America in the 1930s; by the 195Os, approximately one-third of the population of the region resided in urban areas, and by 1980, two-thirds of the total population was urban (Table 3).' In countries where economic growth began early (Argentina, Brazil, Chile, Colombia, Cuba, Mexico, Uruguay, and Venezuela), approximately 70 percent of the population is concentrated in urban areas, but Haiti, Bolivia, and several Central American countries, such as Honduras, Guatemala, and El Sal- vador, remain primarily rural. The urban lifestyle-which includes social dif- ferentiation, division of labor, greater availability of community services, and greater access to popular goods-has generally characterized Latin American life in the last several decades. Nationwide television networks and an upgraded network of roads link regions and consolidate markets for goods, services, and labor nationwide (Wilkie 1984). Features of urban life are now more available in rural areas as well. ' The definition of an urban area differs from countrv to country. When a uniform definition is used-population centers with more than 20,000 inhabitants-the propor- tion is considerably smaller, although the trend remains the same. 62 Prevalence and Mortality Table 3. Percentage of population living in urban centers, by country in Latin America,* 1950-1980 Census definition of urban area+ 20,000 or more inhabitants Country - Argentina Bolivia Brazil Chile Colombia Costa Rica Cuba Dominican Republic Ecuador El Salvador Guatemala Haiti Honduras Mexico Nicaragua Panama Paraguay Peru Uruguay Venezuela Total 1950 1960 62 74 35 24 36 46 60 68 39 53 33 35 51 55 24 30 28 36 36 39 25 34 12 15 18 23 43 51 35 41 36 42 35 36 41 47 57 72 35 63 37 44 1970 1980 78 83 38 45 56 67 75 81 57 64 39 43 60 68 39 50 40 47 39 43 34 37 20 24 28 35 59 66 47 51 47 50 37 42 58 64 82 85 72 79 58 65 1960 1970 59 66 23 27 27 36 51 61 34 44 19 26 39 43 19 30 27 33 18 21 15 16 10 13 11 18 29 35 20 31 33 39 22 27 27 39 60 63 47 59 32 40 1980 70 34 46 68 54 30 48 41 40 25 19 17 24 43 37 41 32 47 66 67 47 Source: Wilkie and Ochoa (1989); Centro Latinoamericano de Demografia (1990). *Excludes Belize and Puerto Rico. `Differs by country. The trend toward urbanization in Latin America has concentrated and consolidated the market for to- bacco products, as it has for most other consumer items. The techniques of demand creation (described in Chapter 2) largely depend on an easily reachable mass audience-an audience which in Latin America has demonstrated persistent relative and absolute growth. Educational Opportunities As a by-product of urbanization, access to edu- cation in Latin America has increased substantially in recent decades. Only 58 percent of the total population aged 6 to 11 years was enrolled in primary schools in 1960 (Table 4). By 1987, this enrollment had increased to 86 percent. Since 1970, enrollment in secondary Table 4. Percentage of population in Latin America and the Caribbean enrolled in school, by age group and sex, 1960-1987 Year 6-11 years 12-17 years Total Males Females Total Males Females 1960 57.7 58.1 57.4 36.3 38.7 33.9 5.7 7.1 4.3 36.9 38.2 35.5 1970 71.0 70.7 71.3 49.8 52.1 47.5 11.6 13.6 9.7 48.3 49.5 47.1 1975 76.3 76.4 76.1 58.0 59.8 56.1 18.9 21.0 16.8 54.3 55.6 52.9 1980 82.4 82.8 81.9 62.6 63.6 61.6 23.6 25.1 22.0 58.8 59.8 57.7 1985 85.2 85.8 84.7 66.2 67.3 65.1 23.8 24.8 22.8 60.4 61.2 59.4 1986 85.9 86.6 85.3 66.7 67.8 65.6 24.2 24.9 23.5 60.8 61.7 60.0 1987 86.3 86.9 85.7 68.2 69.2 67.2 25.1 25.8 24.4 61.8 62.6 60.9 18-23 vears Total Males Females 6-23 years Total Males Females Source: United Nations Educational, Scientific, and Cultural Organization (1989) schools has also increased significantly, and the num- ber of university students has dramatically increased as well-from 500,000 in 1960 to 6 million in 1990 (Brunner 1990). Women continue to have somewhat less access to education than do men, but since 1960, gains in enrollment have been equivalent for both sexes (Table 4). The gains in education have brought a more literate and more discriminating group of consumers to the marketplace. The net effect may be complex- although sophisticated consumers may be more ex- posed to tobacco marketing techniques and are more likely to have disposable income for tobacco products, they may also have better knowledge of the adverse health effects of tobacco use. Data on smoking preva- lence and educational status are ambiguous (see "Prevalence Estimates" later in this chapter). Income Distribution and the Labor Force In Latin America between 1950 and 1980, the agricultural sector of the labor force declined, but both the trade sector and the manufacturing sector in- creased (4.5 percent and 3.3 percent per year, respec- tively) (Economic Commission for Latin America and the Caribbean [ECLACI 1989). In urban areas, more than one-third of the total labor force is employed in these two sectors. A study of occupational stratifica- tion in six countries found a large increase in non- manual employment (De Oliveira and Roberts 1989). But despite an apparent increase in the size of the middle class in Latin America, theunevenness of income distribution still exceeds that of the United States (Table 5). In 1975, high-income groups in Latin Amer- ica accounted for a larger percentage of total income than did the corresponding groups in the United States. Conversely, the lowest income group ac- counted for a much smaller percentage of total income in Latin America than in the United States (7.7 vs. 17.2 percent, respectively). Perhaps more important, how- ever, the average income of the lowest income group in Latin America was one-tenth that of the lowest income group in the United States. These income disparities have persisted into the mid-1980s. For se- lected Latin American and Caribbean countries for which data are available (Table 61, the concentration of income in the upper 20 percent of households is substantially greater than for North America. A critical socioeconomic factor has been the in- creasing entry of women into the labor force. Among developing nations worldwide during the 196Os, the highest percentage of female nonagricultural wage earners was found in Latin America (Anker and Hein 1987). Between 1970 and 1980, the size of the female labor force increased at twice the rate of that of the male labor force (5.1 vs. 2.5 percent, respectively) (ECLAC 1989). The main sociodemographic effect of changes in the labor force has been the creation of a group of middle-income wage earners with increased dispos- able income, a group in which women figure promi- nently. Such a consumer group is of interest to the tobacco industry because it may serve as a focus for creation of demand for tobacco (Ernster 1983). Table 5. Income distribution in Latin America* and the United States, 1960 and 1975 ~- __.~~ -~ ~~~~ ~~~ _~ Percentage of total income Annual income per family+ Income bracket 1960 1975 1960 1975 Latin America 10% richest 46.6 47.3 11,142 15,829 20% below the richest 10% 26.1 26.9 3,110 4,497 30% below the richest 10% 35.4 36.0 2,542 3,636 60% poorest 18.0 16.7 833 1,095 40% poorest 8.7 7.7 520 6-18 United States 10% richest 28.6 28.3 15,538 21,488 20% below the richest 10% 26.7 26.9 13,490 17,807 30% below the richest 10% 36.7 36.9 11,577 15,891 60% poorest 34.8 34.8 6,099 8,276 40% poorest 17.0 17.2 4,976 6,635 Source: Portes (1984). *Excludes Belize, Cuba, and Puerto Rico. `In 1970 U.S. dollars. 64 Prevalence and Mortality Table 6. Income distribution in selected countries of the Americas Country Year Percentage of household income (by percentile group) Lowest Second Third Fourth Highest Highest quintile quintile ouintile auintile auintile 10% Brazil 1983 Canada 1987 Colombia 1988 Costa Rica 1986* Jamaica 1988+ Peru 1985-1986+ United States 1985* Venezuela 1987 Source: The World Bank (1991). Based on per capita income. `Based on per capita expenditure. 2.4 5.7 5.7 11.8 4.0 8.7 3.3 8.3 5.4 9.9 4.4 8.5 4.7 11.0 4.7 9.2 1 10.7 22.8 62.6 17.7 24.6 40.2 13.5 20.8 53.0 13.2 20.7 54.5 14.4 21.2 49.2 13.7 21.5 51.9 17.4 25.0 41.9 14.0 21.5 50.6 46.2 24.1 37.1 38.8 33.4 35.8 25.0 34.2 The four main factors discussed here have all affected prevalence of smoking in Latin America, which is summarized below. The economic signifi- cance of these sociodemographic changes is discussed further in Chapter 4 (see "Economics of the Tobacco Industry"). Prevalence Estimates Systematic surveillance of smoking prevalence has generally not been conducted for most regions of Latin America. Consistent time series and uniform methods of data collection are just now being devel- oped (see Chapter 6). Available information on prev- alence is primarily derived from the following sources: an eight-city survey conducted by the Pan American Health Organization (PAHO) in 1971 (Joly 1977); a set of surveys conducted by the Gallup Orga- nization for the American Cancer Society in 1988 (Gal- lup Organization 1988); and a set of reproductive health surveys conducted by local public sector or private sector agencies, principally sponsored by the U.S. Agency for International Development, with technical as&stance provided by the Centers for Dis- ease Control (CDC). Prevalence data from additional surveys (Tables 16-19) have been compiled by PAHO and are available in a companion document to this report (PAHO 1992). Very few of the almost 150 sur- veys compiled have been formally published, and they differ widely by sampling strategy, target popu- lation, method of weighting and adjustment, and re- porting format. Definitions of various categories of smokers also differ across studies (e.g., heavy vs. light, Table 7. Prevalence of cigarette smoking (%) among persons aged 1.574 in eight cities* in Latin America, adjusted for age and sex,+ 1971 -- Total Men Women Current Former Current Former Current Former City smoker smoker smoker smoker smoker smoker La Plata, Argentina 40 8 58 13 26 5 Sso Paulo, Brazil 37 4 54 10 26 3 BogotA, Colombia 36 7 52 7 24 3 Caracas, Venezuela 36 8 49 21 2 Santiago, Chile 35 5 47 1; 20 4 Mexico City, Mexico 30 5 45 8 17 3 Guatemala City, Guatemala 22 6 36 11 10 9 Lima, Peru 21 4 34 7 7 1 Source: Joly (1977). +In order of prevalence ot current smokers. Adjusted by the direct method, based on the age distribution of respondents. regular vs. occasional, and current vs. former). Most surveys provide crude prevalence for the group exam- ined (number of smokers divided by number of per- sons surveyed), and some surveys report results by age, sex, ethnic group, residence, and occupation. Comparison of prevalence by country or by group within countries is problematic, and the only sum- mary statistics are ranges, distributions, and medians. Prevalence Reported by the Pan American Health Organization by using the combined total population of the eight cities as the standard. The age-adjusted prevalence of smoking ranged from 21 to 40 percent. For men, it ranged from 34 to 58 percent (median = 48 percent), and for women, from 7 to 26 percent (median = 21 percent). The prevalence for U.S. males and females at the time was 44 percent and 30 percent, respectively; however, the figures are not directly comparable to those of the PAHO survey because of methodologic differences (U.S. Department of Health and Human Services [USDHHSI 1989). The 1971 PAHO survey reported prevalence of Most smokers (98 percent) reported that they cigarette smoking for persons in eight major cities of smoked cigarettes rather than cigars or pipes (Joly Latin America (Table 7). Estimates were age-adjusted 19771, and most of them (71 percent of men and 79 Table 8. Standardized ratio* of cigarette smoking among persons aged 15-74 in eight cities of Latin America, by sex and level of education, 1971 No Men Second- Post- Primarv arv Women Second- Post- secondary school No schooling Primary ary school school secondary school City schooling school school Bogota, Colombia Current smoker Former smoker Caracas, Venezuela Current smoker Former smoker Guatemala City, Guatemala Current smoker Former smoker La Rata, Argentina Current smoker Former smoker Lima, Peru Current smoker Former smoker Mexico City, Mexico Current smoker Former smoker Santiago, Chile Current smoker Former smoker SBo Paulo, Brazil Current smoker Former smoker All eight cities Current smoker Former smoker 0.9 1.0 1.0 1.0 0.7 0.8 1.2 2.0 0.8 1.2 0.8 1.0 1.4 1.2 0.9 2.0 1.1 1.1 0.9 0.9 1.4 1.1 0.9 1.1 - 0.8 1.1 1.8 1.4 0.7 1.1 1.0 1.6 0.9 0.9 1.1 0.6 0.7 1.7 2.3 1.1 0.9 1.1 1.0 1.1 0.8 0.8 1.8 0.8 1.1 1.0 1.0 1.6 1.1 0.9 1.2 0.7 0.7 1.2 1.4 0.6 1.2 1.9 1.6 0.8 1.0 1.4 1.3 0.8 0.7 0.5 0.6 1.4 2.1 1.1 1.2 1.1 1.4 1.1 1.0 1.1 0.7 0.8 1.0 1.6 - 1.1 0.9 1.5 1.4 1.1 0.8 0.7 0.9 0.8 1.1 1.1 0.7 0.8 0.2 1.1 1.1 1.2 0.6 0.8 1.5 2.5 0.8 1.5 1.0 1.0 1.1 1.0 1.1 0.9 1.2 1.1 0.6 1.3 1.3 0.9 1.1 1.1 0.9 0.5 1.2 1.1 2.0 0.9 1.1 0.7 1.0 1.1 0.8 0.8 0.9 1.2 0.9 0.8 1.6 1.6 Source: Joly (1977). Each entry represents the age-adjusted rate for the subgroup divided by that for the total sample. Educational categories are assumed to have the same age distributions within each sex group. 66 Prevalence and Mortality Table 9. Prevalence of smoking (%) in 12 Latin American countries, 1988 Total Men Women Current Former Current Former Current Former Country smoker smoker smoker smoker smoker smoker Chile 39 14 41 17 31 11 Uruguay 32 16 44 25 23 9 Colombia 28 16 37 21 18 11 Costa Rica 28 16 35 23 20 10 Peru 22 12 28 19 17 6 Brazil 38 12 40 18 36 6 Ecuador 27 7 39 10 16 5 Mexico 27 10 37 13 17 6 Argentina 35 17 43 25 27 9 Honduras 24 15 36 19 11 12 El Salvador 25 8 38 10 12 5 Venezuela 27 15 32 21 23 11 Source: Gallup Organization (1988). percent of women) preferred light-tobacco cigarettes (Joly 1977). The percentage of smokers who smoked light-tobacco cigarettes was greater among persons with at least a high school education-from 54 to 77 percent for men and from 58 to 89 percent for women. Preference for dark tobacco was much greater among older (55 to 74 years) than among younger (15 to 24 years) persons (40 vs. 14 percent). Although all cities reported a lower prevalence of smoking for women than for men, the difference was less for areas in which overall consumption was higher. For example, in La Plata, Argentina, and Ca- racas, Venezuela, the prevalence of smoking for women was approximately half that for men. How- ever, in Lima, Peru, the prevalence of smoking for women was one-fifth that for men. Furthermore, in almost all sample populations, the age-adjusted prev- alence of cigarette smoking increased with educa- tional level for women but not for men (Table 8). In most areas, the prevalence of smoking for women with postsecondary school education was about two times higher than that for women with no schooling- evidence that education may have served demand creation rather than hazard recognition. However, the incidence of quitting was also greater among better-educated women than among better-educated men; thus, several factors may have been operating simultaneously. In 1971, the proportion of heavy smokers (de- fined as persons who smoke 20 or more cigarettes per day) was greater for men (29 percent) than for women (15 percent). In addition, more men than women began smoking before age 16 (33 percent and 23 per- cent of those who smoke, respectively). Imitation of friends and companions was the reason adolescents most often gave for starting to smoke. Prevalence Reported by the Gallup Organization The only other multicountry survey was con- ducted by the Gallup Organization in 12 countries in 1988 (Tables 9,16-18). Unfortunately, the methods of the 1988 Gallup survey and the 1971 PAHO survey differed substantially. The sampling frame and meth- odology were not reported in detail for the Gallup survey, although some weighting scheme was used, and prevalence was not age-adjusted. Only seven countries were in both surveys. The 1971 PAHO sur- vey focused exclusively on urban areas; the 1988 Gal- lup survey concentrated on urban areas but included rural areas as well. The accuracy and precision of the Gallup survey are difficult to judge, and direct com- parisons with the PAHO survey may be misleading. For example, data from the Gallup survey suggest that the overall prevalence of smoking decreased in the seven countries included in both surveys (Tables 7 and 9), but results from other surveys (Tables 16-18) are not consistent with these findings. Comparisons within each survey may be legiti- mate, although they must still be interpreted with caution. In the 1988 Gallup survey, the overall preva- lence of smoking was higher in countries that under- went early modernization, such as Chile (39 percent), Brazil (38 percent), Argentina (35 percent), and Uru- guay (32 percent). Overall prevalence was lower in Prezwleme nnd Morfalify 67 Table 10. Male-to-female ratio of smoking prevalence in seven Latin American countries, 1971 and 1988 Country 1971 1988 Argentina 2.4 1.6 Brazil 2.7 1.1 Chile 1.8 1.3 Colombia 2.5 2.1 Mexico 2.7 2.2 Peru 5.3 1.6 Venezuela 1.8 1.4 Source: Joly (1977); Gallup Organization (1988). less economically developed countries, such as Peru (22 percent), Honduras (24 percent), and El Salvador (25 percent). In both surveys, a higher proportion of men than women were heavy smokers, although the definition of heavy smoking appears to differ between the two surveys. The difference in prevalence by sex has decreased substantially (Table 10). In several countries (particularly Brazil and Chile), almost as many women as men are smokers. Prevalence Reported by Reproductive Health Surveys Since the late 197Os, CDC, in collaboration with national investigators, has surveyed reproductive health practices of women in Latin America. Most of these household surveys have asked questions about smoking. Additional household surveys of young adults (men and women aged 15 to 24 years) have also asked about smoking practices. These surveys pro- duced weighted prevalence estimates representative of the area studied. The overall results have not been age-adjusted, but age-specific results are directly com- parable. These surveys are discussed together be- cause of the general uniformity of the methods used; other surveys of women of reproductive age are dis- cussed later in this section. Among women of childbearing age, the prevalence of smoking in the late 1980s varied from 6 to 33 percent in the areas studied (Table 11). Again, because of differences in data collection, direct comparisons cannot be made with earlier work, but the data at least suggest that the prevalence of smoking among women in S~O Paulo, Brazil, may have increased-the prevalence for women aged 15 to 44 was somewhat higher in 1986 (31 percent) than that for women aged 15 to 74 in 1971 (26 percent), although lack of methodologic detail pre- vents formal testing. In contrast, the prevalence of 68 Prevalence and Morfalify smoking for women in Guatemala may have declined during that period. Surveys of young adults, conducted in selected Latin American countries in the late 1980s (Table 12), suggest that the smoking initiation rate (also referred to as the rate of smoking uptake) is high in at least some areas. Uptake of smoking is higher in the more- developed countries, although probably in urban areas only. In several countries surveyed (Guatemala, Jamaica, and Costa Rica), prevalence of smoking among young women is low. The increased tendency to smoke among women in urbanized areas is also evident in Brazil (Table 121, where women in the more urbanized southern areas have almost twice the prev- alence of smoking as do women in the northeast. Results from the 1988 survey of young adults in Chile (Valenzuela, Herold, Morris 1989) illustrate some important patterns (Table 13). In this survey, over 1,600 men and women aged 15 to 24 were sam- pled, although the sample size varied for specific ques- tions. In Santiago, 53 percent of the young men and Area Year Brazil+ 1986 Rio de Janeiro 1986 Siio Paul0 1986 South 1986 Northeast 1986 Guatemala3 1983 Guatemala5 1987 Costa Rica" 1986 Jamaica' 1989 Puerto Rico* 1982 U.S.-Mexico Border*' Whites (non- Hispanic) 1979 Mexican-Americans 1979 Table 11. Prevalence of smoking among women of reproductive age W-44 years*), selected areas of the Americas, 1979-1989 Sample Prevalence size (%`c) 5,892 30.6 749 33.0 769 30.8 846 32.2 1,792 29.6 3,670 6.6 5,160 4.0 3,277 12.4 6,112 6.2 2,861 15.6 798 31.6 1,235 18.5 `Age group 1549 years for women in Costa Rica and Jamaica. `All values for Brazil are from Centers for Disease Control (CDC) (1986). tAnderson (1985). kDC (1987a). "Asociaci6n Demogr6fica Costarricense and CDC (1987). _McFarlane and Warren (1989). **Smith, Warren, Garcia-Nwiez (1983). Table 12. Prevalence of smoking among persons aged 15-24, selected countries of the Americas, 1986-1990 Country and city Year Men Women Sample size Prevalence (%) Sample size Prevalence (%) Brazil* 1986 Salvador+ 1987 SBO Pauloj 1988 Curitiba_ 1989 Rio de Janeiro5 1989 Recife_ 1989 Chile (Santiago)" 1988 Costa Rica' 1990 Guatemala** 1987 Jamaica tt 1989 *Centers for Disease Control (CDC) (1986). `Sakamoto, Freire, Morris (1991). *Universidade Federal da Bahia and CDC (1989). %DC (1990a). !Valenzuela, Herold, Morris (1989). :,CDC (1990b). ,,CDC (1987a). ' `National Family Planning Board and CDC (1988) - - 2,479 871 13.9 956 750 33.7 804 950 24.4 913 848 22.5 831 1,154 23.9 989 800 53.3 865 1,405 23.7 1,582 - 2,204 - 2,605 .~. 41 percent of the young women were current smokers, and prevalence of smoking increased with age. For younger people (in these data, persons 15 to 17 years old), the prevalence of smoking approximates the rate of smoking initiation. In Santiago, the initiation rate was 46 percent for men and 34 percent for women. By ages 22 to 24, more than half of both sexes were current smokers, and 22 percent of both sexes stated that they were former smokers. The vast majority of both men 27.3 14.1 26.2 22.0 22.0 12.0 41.0 5.4 2.5 2.6 and women were light smokers: 78 percent of men and 89 percent of women smoked less than 10 cigarettes per day. The proportion of heavy smokers increased with age. With regard to educational attainment and smoking, the 1988 results from Santiago are consistent with those of the PAHO survey of 1971. A greater percentage of educated women were smokers (46 per- cent of women with superior education and 42 percent Table 13. Prevalence of smoking and cluantitv smoked among; persons aged 15-24, Santiago, Chile, 1988 Group Women Total 15-17 18-19 20-21 22-24 Current smoker Former smoker Less than one-half pack per day One-half pack or more per day 41.0 22.7 88.5 11.3 33.9 44.0 36.0 52.1 24.1 20.7 23.8 21.6 93.0 89.4 83.1 86.5 6.0 10.6 17.0 13.5 Men Current smoker 53.3 46.0 60.1 55.2 56.2 Former smoker 22.3 25.4 19.0 20.8 21.9 Less than one-half pack per day One-half pack or more per day Source: Valenzuela, Herold, Morris (1989). 78.2 85.6 75.5 76.5 73.7 21.8 14.4 24.5 23.5 26.3 PrezTaleuce and Mortality 69 Table 14. Prevalence of smoking and quantity smoked among persons aged 15-24, by educational level and sex, Santiago, ChGe, 198h Group Women Current smoker Former smoker Less than one-half pack per day One-half pack or more per day 41.5 24.6 90.1 9.9 Men Current smoker 56.7 Former smoker 23.6 Less than one-half pack per day 79.8 One-half pack or more uer dav 20.2 Source: Valenzuela, Herold, Morris (1989). *l-8 years. +9-l 2 years. b12 years. Basic* or less of women with basic education or less), but the reverse was true for men (47 percent vs. 57 percent for the corresponding educational levels) (Table 14). Women with greater educational attainment also tended to smoke more (one-third smoked more than 10 ciga- rettes per day). The prevalence of smoking as a func- tion of the educational level of the father of the respondent followed the pattern for the educational level of the respondent. History of pregnancy appeared to have little ef- fect on the prevalence of smoking among women in Santiago (Table 15). On the contrary, prevalence of smoking was slightly higher for women who had been pregnant (43 percent) or who had given birth (47 percent) than for women who had never been preg- nant or had never given birth (around 40 percent for both groups). Since the data are not age-adjusted, this difference may result from the generally lower age distribution of women who have never been pregnant. The data suggest that pregnancy has little influence on the smoking habits of the population studied. The data from Chile are not necessarily general- izable to Latin America as a whole, but they support the supposition that smoking is common among young people in some of the more-developed coun- tries and that the quantity smoked is not great. Al- though the results do not permit the calculation of a single estimate of the prevalence of smoking among young people in Latin America, they do suggest that Educational level Middle+ Middle (incomplete) (complete) Superior* 38.4 42.3 46.4 22.4 22.6 20.6 91.8 92.4 66.7 7.5 7.6 33.3 55.0 52.3 46.5 22.4 22.7 19.3 81.4 77.9 66.0 18.6 22.1 34.0 prevalence varies by level of socioeconomic develop- ment and that prevalence may be over 50 percent in some areas. Additional Prevalence Estimates Reported Since 1980 PAHO has assembled prevalence data, as well as some information on knowledge and attitudes, from country-specific surveys (Tables 16-19). Most of these surveys report a crude prevalence for the population studied, and as noted, the methodologies of these surveys differ substantially. Theoverall prevalence of current smoking varies widely in Latin America and the Caribbean-from 6 Table 15. Prevalence of smoking (%I among women aged 15-44, by reproductive history and smoking status, Santiago, Chile, 1988 - Pre nant P At least Smoking Never at east No live one live status pregnant once births birth Current smoker 40.3 43.3 39.6 46.6 Former smoker 22.4 23.3 23.0 21.4 Never smoker 37.3 33.3 37.4 32.0 Source: Valenzuela, Herold, Morris (1989). 70 Prevalence and Mortality percent in rural La Paz, Bolivia, to 49 percent in Port0 Alegre, Brazil. Prevalence of smoking is higher for men than for women. The distribution of results (Table 20) from the surveys of adults (Table 16)--dis- played as a stem-and-leaf plot (Tukey 19771-reveals that the prevalence for men is centered in the 30 to 49 percent range (median = 37 percent); 74 percent of observations were greater than 30 percent. For women, most results were in the 10 to 29 percent range (median = 20 percent); 24 percent of observations were greater than 30 percent. Most reports of low preva- lence for women were from less-developed, predom- inantly rural areas. A similar rural-urban gradient was also found for men. In general, crude prevalence was highest in the Andean region, the Southern Cone, and Brazil (Table 16). Prevalence tended to be intermediate in Central America, Mexico, and the Latin Caribbean and lowest in the other Caribbean countries (Table 16). Lifetime prevalence (51 percent) was reported for men in Ja- maica. For Trinidad and Tobago, a 42 percent preva- lence is given for men in a single urban area. The available information suggests that for male, urban dwellers in the more-developed countries of Latin America and the Caribbean, the prevalence of smok- ing exceeds 50 percent; for rural women in less- developed countries, the prevalence is less than 10 percent. The data do not permit calculation of a single estimate of the prevalence of smoking in the region, since no unified, planned prevalence survey of the region has been attempted. Cigarette smoking was also common among physicians. The range for the 11 studies that reported prevalence among medical students, physicians in training (residents or house staff), and physicians was 17 to 49 percent (Table 16). Prevalence of smoking for adolescents appears to follow a pattern similar to that for adults (Table 17). Prevalence is higher for young men than for young women and higher in urban areas of the more- developed countries. The regional pattern is also similar, except that smoking among young people appears to be more common in the non-Latin Caribbean than in Central America, Mexico, and the Latin Caribbean. The prevalence of smoking for adolescents is high in some areas-perhaps even higher than the prevalence for adults. A prevalence of greater than 30 percent is reported by almost half of the surveys for young men and almost one-third of the surveys for young women. Surveys of women of childbearing age have been conducted in some Latin American and Caribbean countries (Table 18). The results generally confirm those cited earlier (also included, in part, in Table 18). The prevalence of smoking varies considerably; 25 percent of surveys reported a prevalence over 30 per- cent, and more than half reported a prevalence greater than 20 percent. Since women of reproductive age span the adolescent and adult years, younger women may disproportionately contribute to the high overall prevalence of smoking in some areas. The few studies available about public knowl- edge and attitudes with regard to smoking suggest a high level of awareness of the general health hazards of tobacco use (Table 19). One study in Cuba indicated a high level of public approval for an indoor ban on smoking. In contrast, a survey among physicians in Paraguay showed that only 30 percent agreed with the statement that smoking is undesirable. Information on public awareness of the specific health risks of smoking and on the degree to which smokers perceive a personal risk is not available for Latin America and the Caribbean; data for the United States, however, have been considered in detail (USDHHS 1989). Col- lection of such information for Latin America and the Caribbean will be important to enhancing tobacco control in those regions (see Chapter 6). Another aspect of the prevalence of smoking in the Americas is smoking patterns among Hispanic persons who reside in the United States. A large prob- ability survey of Hispanic Americans (Hispanic Health and Nutrition Examination Survey [Hispanic HANES]), conducted in 1982 to 1984, revealed that, for both men and women, the pattern of smoking differs among persons of Mexican origin in the southwest United States, persons of Puerto Rican origin in the New York City area, and persons of Cuban origin in the Miami area. For all three groups, the weighted prevalence of cigarette smoking was higher for men than for women (Table 21). But persons of Puerto Rican or Cuban origin were more likely than persons of Mexican origin to be heavy smokers (Haynes et al. 1990). Compared with the prevalence of smoking for the general U.S. population WSDHHS 19891, the prev- alence of smoking was higher for men of all three Hispanic groups and for women of one group (Puerto Rican origin). The Hispanic HANES survey of 1982 to 1984 also showed that with decreasing income and educational attainment, the prevalence of smoking increases among Hispanic men (Haynes et al. 1990). In addition, for women of Puerto Rican origin residing in the New York City area, the prevalence of cigarette smoking is approximately twice that of women in Puerto Rico (Becerra and Smith 1988). Approximately five years after the Hispanic HANES survey, the National Health Interview Survey (NHIS) revealed that the prevalence of smoking for all these groups had declined substantially, parallel with the decline in prevalence in the general U.S. population (Table 21) (Schoenboml989). Detailed analysis of prev- alence of cigarette smoking among successive birth cohorts, however, shows little reduction for women of Mexican origin and an increase for women of Puerto Rican or Cuban origin (Escobedo, Remington, Anda 1989). Direct comparison with data for populations in the areas of origin is not possible (Table 16) because of differences in sampling methods, but thedata suggest that some trends for Hispanic persons residing in the United States may be the same as those for the general U.S. population (Escobedo, Remington, Anda 1989; Escobedo et al. 1990; Harris 1983). Although preva- lence of smoking has declined among Hispanic men and women, uptake of smoking is increasing among young Hispanic women. In general, persons of His- panic origin in the United States reflect a mixture of the cultural forces in Latin America and North America. Table 16. Prevalence of tobacco use among adults reported by surveys in Latin America and the Caribbean, 1980s and 1990s Re ion % Survey an Country Year Sample area Number Age I Andean Area Bolivia 1983 La Paz 945 1986 Sucre 1,028 1986 Rural La Paz 1,060 1986 Urban La Paz 1,058 1987 Physicians in La Paz 72 215 215 215 215 Colombia 1980 Nationwide 6,277 1985 Medellin (excludes 2,432 persons of low socioeconomic status) 1987 Urban areas 2,400 1988 Nationwide 1,512 Ecuador 1988 Quito, Guayaquil, 3,657 and three rural capitals 1988 Urban areas 1,323 215 216 216 Sponsor Bolivian Cancer Foundation Department of Mental Health Department of Mental Health Department of Mental Health Osorovic and Rios-Dalenz National Institute of Health University of Antioquia Public Health School Drug Survey 18-60+ American Cancer Society/Gallup Organization 20-65 Ministry of Public Health, Our Youth Foundation Peru 1990 Quito 1,805 1980 Households in 2,167 Lima/Callao 1985 Male firearm 359 licensees in Lima 13-60+ American Cancer Society/Gallup Organization 210 Ministry of Public Health 12-45 Police Force, Antidrug Unit 18-70 Police Force, Antidrug Unit Source: Pan American Health Organization (1992). *Given for current daily smokers/occasional smokers, or for the former only. +Smoked during the previous year. Prevalence* (% 1 Men Women Total ____- 41/37 32/33 36/35 35 18 28/41 6 3 6/48 46/38 29/33 38/36 35/17 52 26 39 30+ 43 25 34+ 37 18 28 27127 11/20 22/24 39 16 27 23/27 49/14 23/11 36/13 36/23 72 Prevalence and Mortality Table 16. Continued Region Survey a&I Country Year Sample area Number Peru (contd.) 1987 Lima 1,800 1988 Urban areas 400 1989 Towns >2,500 population 6,761 Venezuela 1984 Nationwide 1986 Caracas 1988 Urban areas 1989 Southern Cone Argentina 1981 1988 Caracas 1988 Buenos Aires 306 Buenos Aires 128 pediatric hospital staff Urban areas 826 Chile 1984 1985 1987 Paraguay 1988 1989 1989 Uruguay 1984 1985 1988 1989 852 400 Santiago 1,050 Twelve cities 2,700 Three communities 1,800 near Santiago Medical students 375 and doctors at Catholic Univer- sity Medical School Less than one-half 394 of all medical students Physicians 837 nationwide Montevideo 396 Ministry of Public 525 Health employees Urban areas 799 Fourth-year medical students in Montevideo Age Sponsor ~~____ 15-50 Peruvian Public Opinion 18-35+ American Cancer Society/Gallup Organization 12-50 Information Center, Education for the Prevention of Drug Abuse Prevalence* (7r) Men Women Total 68 40 28 17 22 42 13 26$ Ministry of Health Ministry of Health 18-64 American Cancer Society/Gallup Organization Ministry of Health 32 23 38 42 27 36 15-74 Alvarez 39 27 20-55 Pediatric Hospital 48 49 18-50+ American Cancer Society/Gallup Organization >15 Public Health School >I5 Gallup Chile >15 Catholic University Department of Public Health 43 27 33 35 34/10 35/16 28/11 30/11 31 32/11 33/13 Estigarribia 25 24 25 16-36 Martinez 18 14 17 20-80 Chaparro 218 Prevention Volunteers 218 Epidemiology Division, Ministry of Health 18-50+ American Cancer Society/Gallup Organization 22-26 Ruocco 35 49/9 45 44 24 32 31/14 40/12 45 45 23 32 24 `Given for current daily smokers/occasional smokers, or for the former only. ISmoked during the previous month. Table 16. Continued Region Survev ana Country Year Brazil 1981 1982 1987 1987 1988 1988 1989 Sample area Number Physicians in Port0 Alegre Medical association P&to Alegre Siio Paul0 Two state capitals 1,297 Twelve state capitals Physicians in Rio de Janeiro Central America5 Costa Rica 1986 1987 1988 Households nationwide Nationwide Nationwide 35,000 2,700 1,213 El Salvador 1988 Nationwide, urban 1,300 Guatemala 1982 1987 1989 1989 Guatemala City 2,403 University of San 170 Carlos students and teachers Urban areas 7,372 Finance Office 350 employees Honduras 1987 1988 Ministry of Health 293 employees Urban areas 1,200 Nicaragua Panama 1988 1983 1986 1989 Employed persons 520 Nationwide 1,631 Health Depart- 11,385 ment employees Health Department 100 pensioners Mexico 1983 1986 1988 1988 1988 Physicians 495 Households 14,528 Urban areas 12,581 National Respira- tory Institute employees Urban areas 2,600 - `Given for current daily smokers. SExcludes Belize. 49 Sponsor Saltz et al. 20-64 Achutti 15-59 Ramos 18-50+ Gallup Organization 18-55 Ministry of Health Campos 215 Office of Statistics 14-60 Alcohol and Drug Dependency Institute 18840+ American Cancer Society/ Gallup Organization 35 14 30 33 11 22 35 20 28 18-40+ American Cancer Society/ Gallup Organization 38 12 25 210 Drug Institute San Carlos Medical School 53 30 47 34 36 34 215 Health Department 38 18 27 Health Department 48 38 44 Ministry of Health 18840+ American Cancer Society/ Gallup Organization ~18 Mount Sinai Medical Center 218 National Cancer Association National Cancer Association 255 National Cancer Association 212 National Health Survey 12-65 Secretary of Health 15-45+ American Cancer Society/ Gallup Organization Prevalence* (X) Men Women Total 26 40 32 27 52 34 45 31 40 36 45 33 28 23 49 38 38 39 36 11 22 24 51 6 41 56 20 10 4 48 13 38 7 33 27 8 38 14 41 18 33 17 26 28 37 17 27 74 Prevalence and Mortality Table 16. Continued Reeion Survev Prevalence* (o/o) ana Country Year Sample area Number Mexico 1989 Physicians in Mexico 818 (contd.) City (telephone) Latin Caribbean" Cuba 1984 Nationwide 4,968 1988 Nationwide 5,933 Dominican 1989 Health Department 704 Republic employees 1989 Nationwide 502 1991 Households in 1,392 Santo Domingo Puerto Rico 1989 Behaviorial Risk 772 Factor Survey, San Juan (telephone) Selected Caribbean countries Anguilla 1989 Islandwide 101 Bahamas 1988 Areawide 933 Bahamas 1989 Areawide 1,000 Jamaica 1987 Household Council 6,007 1987 Household 1,000 Aruba and 1989 Netherlands Antilles Random sample of 623 population (1%) Trinidad and 1981 St. James (Port of 2,491 Tobago Spain) U.S. Virgin 1989 Islands 1989 Household Behavioral Risk Factor Survey (telephone) 2%' population sample after hurricane 141 727 49 Sponsor Menese et al. 217 214 Cuban Institute for Research and Orientation of Internal Demand Cuban Institute for Research and Orientation of Internal Demand Ministry of Health 20-79 Ministry of Health 15-55+ Vincent et al. 218 School of Public Health 23 11 15-74 Health Department 215 Health Department 16-59 Health Department Drug Survey 10/9 20 19 212 210 National Council on Drug Abuse Jamaican Medical Association 51** 25 2/10 7/9 5 11 4 10 15** 6 Ministry of Health 32 13 21 35-69 State government and Medical Research Council (United Kingdom) 42 8 27 218 Health Department 15 Men Women Total 48 26 36 25 22 20 66 14 40% 36 33 35 9 12 11 23 42 *Given for current daily smokers/occasional smokers, or for the former only. "Excludes Haiti. IDefinition of smoking status unavailable. **Smoked during lifetime. Preaaltwe and Mortality 7.5 Table 17. Prevalence of tobacco use among adolescents reported by surveys in Latin America and the Caribbean, 1980s and 1990s Prevalence* (%I -.____- Re ion % Survey an Countrv Year Sample area Number Age Sponsor Men Women Total 51 72 42 63 43 44 61 5 30+ 4 5+ 16+ 6+ 10/22+ 15 15 15+ 16 44 41 64 90 34 71 14 3 69 65 67 37 28 34 51 33 50 75" 32 45 13/15 11 11 16 / 20$ 16+ 27t Andean Area Bolivia 1980 1983 1983 1986 La Paz 18,956 Tarija 120 La Paz 707 La Paz 1,359 Medellin Urban areas 400 Cab, private school 283 14-22 Committee on Drugs 18 Bolivian Cancer Foundation 13-18 Bolivian Cancer Foundation Colombia 1985 1987 1985 lo-15 12-15 16-18 Public Health School Cab, public school 512 National school 7,513 Nationwide 2,599 Nationwide 329 11-25 University of Valle drug survey University of Valle drug survey Education Ministry 10-19 13-19 Ministry of Public Health American Cancer Society/Gallup Organization Lima/Callao 419 12-19 Public school 1,311 <18 Private school 206 <18 University 1,379 15-22 1989 Nationwide 12-19 Police Force, Antidrug Unit Cancer Institute Cancer Institute University of Sacred Heart Drug Abuse Center Caracas 225 12-15 Ministry of Health 1985 1989 Ecuador 1988 1988 Peru 1980 1982 1985 Venezuela 1984 Southern Cones Argentina 1981 1986 Buenos Aires 1,007 15-21 12-15 Chile 1981 Santiago 330 18-20 1986 Rural areas 415 18-20 Tobacco Industry Department of Health Universitv of Conception Department of Health 1986 Uruguay 1975 1980 1984 1987 Santiago 761 Montevideo 10,496 Ten high schools P&to Alegre P&-to Alegre Ten state capitals 1989 Ten state capitals 42,475 18-20 12-16 17-18 10-19 10-19 lo-18 218 lo-18 Brazil Rosito et al. Rosito et al. Barbosa et al. Corlini et al. (Psychotropic Drug Center) 218 1989 Street boys in three cities 1989 Sao Paul0 Corlini et al. 6-18 Moraes et al. 6/27 Source: Pan American Health Organization (1992). Given for current daily smokers/occasional smokers, or for the former only. +Smoked during the previous year. tEver smoked. SExcludes Paraguay. ISmoked during the previous month. 76 Prevalence and Mortality