World's Largest Tobacco Use Study Reveals Tobacco Control Remains A Major Challenge in Low- and Middle-Income Countries

Study of tobacco use in 3 billion people from 16 countries demonstrates powerful pro-tobacco forces still at work, UB researcher and lead author concludes

Release Date: August 17, 2012


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"Our data reflect industry efforts to promote tobacco use," says UB's Giovino, equating tobacco use with Western themes of freedom and gender equality.

BUFFALO, N.Y. - An international survey of tobacco use in three billion individuals, published in the current issue of The Lancet, demonstrates an urgent need for policy change in low- and middle-income countries, according to the University at Buffalo professor who led the research.

"Governments around the world need to start giving economic and regulatory advantages to agricultural products that promote health instead of to products like tobacco that kill people," says lead author Gary A. Giovino, PhD, chair of the Department of Community Health and Health Behavior at the University at Buffalo School of Public Health and Health Professions.

Giovino is an international authority on tobacco use surveys; he previously was chief of epidemiology in the Office on Smoking and Health at the Centers for Disease Control and Prevention (CDC).

He describes the implications of the research in this video (

The survey results, Giovino says, paint a disturbing picture of global tobacco use influenced by powerful and manipulative pro-tobacco forces.

While 100 million lives were lost prematurely due to tobacco use in the last century, the study notes that the World Health Organization estimates that if current trends continue, the number of preventable, premature deaths in this century will be far greater.

"In the absence of effective actions, about one billion people worldwide will die prematurely in the next century from tobacco use," says Giovino, "and most of those deaths and the healthcare and economic costs that come with them, will be borne by lower- and middle-income countries."

Published in a special issue on respiratory medicine, the findings are from the Global Adult Tobacco Survey, (GATS). GATS was created by major national and international health agencies to improve the ability of countries to design, implement and evaluate anti-tobacco efforts.

"This is the largest tobacco use prevalence study ever reported in the scientific literature," says co-author Samira Asma, DDS, Chief of Global Tobacco Control, CDC.

The study focused on 14 low- and middle-income GATS countries (Bangladesh, Brazil, China, Egypt, India, Mexico, the Philippines, Poland, Russia, Thailand, Turkey, Ukraine, Uruguay and Vietnam), making comparisons with the United States and the United Kingdom.

The nationally representative surveys were conducted in GATS countries from 2008 to 2010, via face-to-face interviews with 248,452 respondents. Data on another 188,895 respondents from the U.S. and UK were also included.

The research reveals:

-- 49 percent of men and 11 percent of women in the GATS countries used tobacco (smoked, smokeless, or both)

-- although women's tobacco use rates remain low, women are beginning to smoke as early as men, around age 17 instead of in their 20s

--while tobacco is consumed in various ways, from chewing tobacco and snuff to waterpipes and hand-rolled bidis, most tobacco users (64 percent) smoked manufactured cigarettes

-- China had the highest number of tobacco users at 301 million people (including 52.9 per cent of men) followed by India, with 274 million people ( 47.9 percent of men).

-- Quit ratios were highest in the U.S. and the UK as well as in Brazil and Uruguay, where tobacco control activities are strongest; they were lowest in China, India, Russia and Egypt.

According to Giovino, the magnitude of global tobacco use revealed in the current study reflects powerful pro-tobacco forces that often overpower the less well-funded tobacco control strategies.

"Our data reflect industry efforts to promote tobacco use," he says. "These include marketing and mass media campaigns by companies that make smoking seem glamorous, especially for women. The industry's marketing efforts also equate tobacco use with Western themes, such as freedom and gender equality."

Industry efforts also influence governments to back off of anti-tobacco regulations, he says, adding that in some countries the government owns the tobacco industry. "China National Tobacco, for example, which is owned by the Chinese government, sponsors dozens of elementary schools, where students are subjected to pro-tobacco propaganda. Some messages even equate tobacco use with academic success," says Giovino. "I find that mind-boggling."

The high consumption of manufactured cigarettes is also a direct result of sophisticated technological manipulation, he says. "These products are technologically designed to mask harshness, provide particular taste sensations and increase nicotine delivery," the paper states.

That works not just to keep current smokers smoking but also to make it more palatable for nonsmokers who are experimenting. "These characteristics are designed to ease the transition from experimentation to regular use, especially among young people," Giovino says.

What is needed, he says, is the deliberate allocation of more resources to fully implement tobacco control strategies, such as the MPOWER strategies of the World Health Organization ( that monitor tobacco use, protect nonsmokers, offer help with quitting, warn people about the dangers of tobacco use via large, graphic warning labels on tobacco packages and hard-hitting mass media campaigns, enforce advertising restrictions, and raise taxes on tobacco products.

The research was funded by Bloomberg Philanthropies' Initiative to Reduce Tobacco Use, the Bill and Melinda Gates Foundation and the Brazilian and Indian governments.

Co-authors with Giovino and Asma are Sara A. Mirza, PhD, Jason Hsia, PhD, Jeremy Morton, and Krishna M. Palipudi, PhD of the CDC; Jonathan M. Samet of the Institute for Global Health, University of Southern California; Prakash C. Gupta, ScD, of the Healis-Sekhsaria Institute for Public Health in Mumbai; Martin J. Jarvis of University College London; Neeraj Bhala and Richard Peto of the University of Oxford and Witold Zatonski, MD of the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw and the Institute of Rural Health, Lublin, Poland.

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