1. Children ’ s Exposure to Environmental Smoke / Involuntary Smoking in Developing Countries: Current Situation and Implications for Health and Development Enis Barış 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 Exposure Number of smokers around the globe 2000 1.2 billion smokers globally 83% of global smokers (956 million) live in developing countries Prevalence rate (in 90s) MaleFemale Bangladesh4010 Turkey5926 Vietnam734 Pakistan369 China634 Indonesia632 Russia6314 Philippines7518 Egypt435 Prevalence rate in selected developing countries

7. Intensity of Exposure Global Cigarette Consumption 2000 In 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 LI129521 LMI273343 UMI61310 HI161926 Total6260100 China168827 India94715 LI w/o India3486 LMI w/o China104517

8. Intensity of Exposure Daily 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 behavior: Evidence 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 LMIAt home At public places At home At public places Indonesia6984China5451 Philippines5875India5967 Jordan6761Nepal3647 Russia5573Nigeria3450 Bolivia4662Sri Lanka5668 Venezuela4448Ukraine4972 Uruguay6479Zimbabwe3558 Source: GYTS Survey Data, 1999-00-01

12. Smoking restrictions in various places CountriesHC Facilities Education Facilities BusesWaiting areas Entertainment centers Shopping centers ChinaBBBBBB PhilippinesNNNNNN ThailandBDBDBB IranBBBBBB TurkeyDDDDDD PolandDDNDDD IndonesiaBBDNNN NigeriaBBBNNN MalaysiaBBBBBB 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 Income84237%47% Low Middle Income62827%35% Upper Middle Income17229%10% High Income16218%9% LI and LMI1,47132%82% All Developing1,64233%91% Developed16218%9% Total1,80531%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 India34018.95967 China31417.45451 Indonesia 653.6984 Pakistan 583.2N/A Nigeria 573.23450 Philippines 282.65875 Vietnam 261.5N/a Russia 261.45573 Total99455N/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 India34018.95967 China31317.45451 Indonesia653.66984 Pakistan583.2N/A Nigeria573.23450 Bangladesh512.8N/A Ethiopia292.6N/A Philippines282.65875 Vietnam261.5N/A Russia261.45573 Total 0-14 pop.(top 10)94455.0 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 LI38048%23%21% LMI37155%22%20% UMI8444%5%4% Total83746% 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 LI46159%28%26% LMI36553%21%20% UMI9957%7%6% Total92551% Authors’ calculation

20. Top 10 UMI countries with the highest number of children exposed to ETS at home and public places RegionCountry# of children exposed to ETS at home (mil) # of children exposed to ETS in public places (mil) LACBrazil2532 LACMexico1721 ECATurkey1211 AFRICAS. Africa68 LACArgentina57 EAPKorea Rep.56 ECAPoland55 MENAS. Arabia56 LACVenezuela45 EAPMalaysia45

21. Top 10 LMI countries with the highest number of children exposed to ETS at home and public places RegionCountry# of children exposed to ETS at home (mil) # of children exposed to ETS in public places (mil) EAPChina171.0166.0 EAPIndonesia35.234.2 SAPakistan32.221.9 MENAIran16.014.6 EAPPhilippines15.415.0 MENAEgypt15.213.9 ECARussia14.418.9 EAPThailand8.88.6 MENAMorocco6.76.1 MENAIraq6.55.9

22. Top 10 LI countries with the highest number of children exposed to ETS at home and public places RegionCountry# of children exposed to ETS at home (mil) # of children exposed to ETS in public places (mil) SAIndia199.0227.8 SABangladesh29.734.0 AFRICANigeria18.427.6 EAPVietnam14.013.3 AFRICAEthiopia9.314.0 EAPMyanmar8.58.1 AFRICACongo Dem.Rep.8.012.0 SAAfghanistan6.87.7 MENAYemen5.93.6 SANepal5.56.3

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), women ’ s 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.