1. The epidemiology of smoking in Ukraine: a cross sectional survey undertaken in 2000 Dr Anna Gilmore European Centre on Health of Societies in Transition London School of Hygiene and Tropical Medicine www.lshtm.ac.uk/centres/ecohost/

3. Life expectancy at birth Source: WHO HFA database

4. Risk of dying aged 35-69, Males, 1990 Source: Peto, Lopez et al. Mortality from smoking in developed countries, 1994

5. The Tobacco Industry: State owned until collapse of former SU 1990 RJR and PM airlifted 34 billion cigarettes into the Soviet Union PM, RJR, BAT and Reemtsma began to buy up cigarette factories in early 1990s now 6/11 factories ( >90% production) run by western companies The Ukrainian tobacco industry has a higher share of privatised entities and foreign investment than any other sector of the Ukrainian economy

6. Survey methodology Nationally representative household survey undertaken in Feb-March 2000 amongst adults aged 18+ Multi-stage random sampling technique with the no. of interviews within each area allocated according to population size. Trained interviewers Quality control: In 10% a supervisor present

7. Response 1590 interviews completed and useable Response rate 72% Slightly over represented women compared with men and older compared with younger age groups. Weighted for age and sex. The weighted sample was representative of the Ukrainian population

8. Smoking prevalence rates

9. Age specific rates of smoking amongst women current smokers vs rest p-trend <0.0001

10. Age specific rates of smoking amongst men current smokers vs rest p-trend <0.0001

12. Determinants of current smoking In both men and women: –age - the odds of smoking increase with decreasing age –material hardship particularly unemployment increase the likelihood of smoking –Education & income have no impact –Social networks are protective Women: –those living in cities are 7 times more likely to smoke than those living in villages –women who are separated, widowed or divorced are twice as likely to smoke than those who are married Men: –men whose social position has deteriorated over the last 5 years are more likely to smoke

13. Comparison with recent survey data from other former Soviet countries

14. Tobacco advertising Prior to independence, tobacco advertising was banned. 1996 the government proposed a strict ban on tobacco advertising but the tobacco industry formed a coalition & lobbied parliament. They produced a report from a supposed independent group, the “Association of Independent Advisors” which suggested Ukraine would lose $400M as a result of an advertising ban. As a result, the Government rescinded Now adverts are ubiquitous. Alcohol and cigarette advertising is estimated to make up 60% of all outdoor billboard advertising, Phillip Morris and BAT top the list of advertisers.

15. Advertising has been focused particularly in the major cities and it is likely therefore that the high rates of female smoking in urban compared with rural areas reflect the influence of advertising. In a region previously unexposed to western type advertising, the population is probably more sensitive to the novelty and glamour of tobacco advertising. As Vitaliy Movchanyuk, director of the Ukrainian Health Ministry’s public education institute said: –“The Soviet Union never had such advertising. People are used to it in the West. They have learnt to sift through it for truth and lies… But our consumers are psychologically vulnerable to being manipulated by slick advertising.” (Washington Post Nov 19 1996)

16. Other tobacco control policies Although a number of other tobacco control laws exist, there are numerous loopholes & enforcement is weak For example, although giving out free cigarettes is banned, consumers can “exchange” nearly empty packets for full ones There is little if any enforcement of under age sales Although packets and adverts must carry a health warning, many are poorly visible and cigarettes continue to be sold individually

17. In addition, although smoking is officially banned in public transport and restricted in workplaces, our survey found that a significant proportion of smokers smoke in these venues:

18. Comparison of health beliefs in smokers and non- smokers: the impact of active smoking on health p<0.0005

19. Comparison of health beliefs of smokers and non- smokers: the impact of passive smoking on health P<0.0005

20. Overall our study found: Very high levels of smoking in men Rapidly increasing levels of smoking in women, particularly those in cities suggesting that market liberalisation & the entry of the transnational tobacco companies has led to an increase in the prevalence of smoking Similar epidemiological pattern in Ukraine and other former Soviet republics An urgent need for effective tobacco control policies