Mapping the Global Patterns of Tobacco Consumption
[This post was originally published in July 2013]
My earlier post noted that despite the triple warning on each pack of cigarettes sold in Bosnia and Herzegovina, smoking rates in all the former Yugoslavian republics remain extremely high. Indeed, Serbia is the world’s top smoking nation, Slovenia ranks 7th, Bosnia and Herzegovina 8th, Macedonia 14th, and Croatia 24th. This post examines the issue of smoking rates and tobacco consumption in the global perspective. (The image on the left shows a pack of cigarettes with a warning in Serbian, written in Cyrillic and stating “Smoking kills. Tobacco smoke harms people around you.”)
Unfortunately, maps depicting tobacco consumption available online suffer from various flaws. The Wikipedia map reposted on the left is not dated and does not correspond to the data listed in the same Wikipedia article. It also leaves Serbia, the top cigarette consumer, in the “no data” category.
Some attempts, such as the Washington Post map, leave too many countries in the “no data” category (though Serbia is depicted here), whereas others employ a difficult-to-read color scheme (see, for example, this Guardian map). Finally, the map from the fascinating Tobacco Atlas produced by the American Cancer Society and the World Lung Foundation, reposted on the io9 website, is difficult to decipher and unfortunately lumps the data into merely four categories, concealing some instructive patterns.
Therefore, I have created my own map of cigarette consumption (originally for the GeoCurrents website), using a more visually appealing color scheme, based on the data published in the Wikipedia article “List of countries by cigarette consumption per capita”. The resulting map is posted on the left.
The main pattern revealed by these maps is that cigarette consumption is the highest in Europe, particularly in Eastern Europe, and lowest in Africa, the Caribbean, and South Asia. The top 12 positions, corresponding to “over 2,000 cigarettes per adult per year” category, are occupied by countries in Eastern and Southeastern Europe, with the sole exception of Lebanon, which ranks 11th. Cigarette consumption rates in Western Europe are much lower than in Eastern Europe, with most countries consuming between 750 and 1,200 cigarettes per adult per year. The top smoking rates in Western Europe are found in Spain and Switzerland, ranking 19th and 20th, respectively. Iceland has the lowest cigarette consumption rate in Europe, 477 cigarettes per average adult annually.
Manufactured cigarettes, however, are not the only way that tobacco is consumed. In Europe, dry snuff (powdered tobacco that is inhaled through the nose or taken orally) has been widely consumed, though its use is now in decline. Elsewhere in the word, other alternatives to manufactured cigarettes are common. Although Scandinavian countries consume relatively few cigarettes, moist snuff remains very popular there. Known also as snus, khaini, shammaah, nass, or naswa, moist snuff consists of ground tobacco held in the mouth between the cheek and the gum; manufacturers are increasingly packaging moist snuff into small paper or cloth packets to make the product more convenient. Tobacco pastes or powders are similarly used, placed on the gums or teeth. The popularity of moist snuff (or “dipping tobacco”) in the US has been growing in recent years. The same is true in several other parts of the world, although moist snuff is now banned in several countries, including Australia and most of the EU countries (though Sweden is exempt from this ban due to the traditionally high usage of snus in that country).
In Asia, the highest rates of cigarette consumption are found in South Korea (13th), Kazakhstan (15th), and Japan (17th). China trails closely behind on a per capita basis, ranking 21st, and has the largest absolute consumption numbers in the world. Southeast Asia, South Asia, and the Pacific Islands overall have relatively low cigarette consumption rates. Here the highest figure is found in Indonesia, where an average adult consumes slightly over a thousand cigarettes annually. This number seems to be misleading, however, as it apparently does not include kreteks, cigarettes made from a clove-tobacco blend. Particularly popular in Indonesia, kreteks can also contain a wide range of exotic flavorings as well as eugenol, an essential oil extracted from cloves, which has an anesthetic effect, allowing for deeper and more harmful smoke inhalation. Also left out are the figures for the consumption of bidis in India and elsewhere in South Asia. Bidis consist of a small amount of crushed tobacco, hand-wrapped in dried temburni or tendu leaves, and tied with string. Despite their small size, bidis tend to deliver more tar and carbon monoxide than manufactured cigarettes because users must puff harder to keep them lit.
Over 25 distinct types of smokeless tobacco are produced worldwide, including both commercialized and local or homegrown products, used both orally and nasally. Various non-smoked forms of tobacco are particularly popular in India, Bangladesh, Myanmar, as well as in Madagascar. (Moist snuff, mentioned above in connection with Scandinavia, is included in this category as well.)
In the Pacific, consumption of manufactured cigarettes is quite low. However, an alternative tobacco product is prevalent in Papua New Guinea—tobacco sticks, made from locally grown sun-cured tobacco and wrapped in cigarette paper (also referred to as “handrolled brus”).
In the Middle East and North Africa, cigarette consumption rates vary dramatically. Tunisia has the highest figure in the region and ranks 23rd globally; an average Tunisian adult consumes 1,628 cigarettes annually. In contrast, Qatar ranks 124th in cigarette consumption, with merely 1/6 of the per capita cigarette consumption of Tunisia. Tobacco use is high in Israel, at over 1,000 cigarettes per adult per year. But once again, manufactured cigarettes are not the only way tobacco is consumed in North Africa and the Middle East, where water pipes (also known as shisha, hookah, narghile, or hubble-bubble) are particularly popular. Variations in water-pipe use may account for some of the discrepancies in the cigarette consumption between the various countries in the region. Water pipes operate by water filtration and indirect heat. Flavored tobacco is burned in a smoking bowl covered with foil and coal; the smoke is first cooled by passing through a basin of water and is then consumed through a hose and mouthpiece.
A sharp contrast marks the smoking rates in Australia and New Zealand, which rank 50th and 83rd, respectively. The average Australian consumes nearly twice as many manufactured cigarettes as a New Zealander does. However, the issue is muddled by the fact that roll-your-own cigarettes are relatively common in New Zealand .
The United States as a whole is found in the middle category, with an average American consuming 1,028 cigarettes annually. However, the U.S. is far from uniform in its smoking rates, as can be seen from the CDC map reposted on the left. Large regional differences in smoking rates are apparent, with Kentucky, West Virginia, Oklahoma, and Mississippi topping the list, and California and Utah posting significantly lower rates. The prevalence of cigarette smoking also varies substantially across population groups. For instance, smoking is more common among Native Americans (32%), followed by non-Hispanic whites and blacks (22% in each group). Hispanics and Asians have the lowest smoking rates, 16% and 13%, respectively. The prevalence of smoking also generally decreases with increasing education. Young adults aged 18-24 and 25-44 have the highest smoking rates of all age groups (24%). Likewise, the prevalence of smoking is higher among adults living below the poverty line (30%) than among those at or above the poverty line (21%). Curiously, persons with mental illness have a higher smoking rate than the general population.
Despite recent decreases of smoking prevalence, average cigarette consumption in the US is still about 20% higher than in Canada and nearly three times higher than in Mexico. In Latin America, Cuba is by far the biggest consumer of manufactured cigarettes (besides the famous local cigars), followed by Argentina, Chile, and Uruguay. The rest of the region is found in the lowest cigarette consumption category.
Sub-Saharan Africa uniformly has very low cigarette consumption rates, regardless of socio-economic development levels. This pattern may be explainable in part by the relatively high prices of manufactured cigarettes throughout sub-Saharan Africa (see map on the left).* In nearly all countries in the region, the Relative Income Price of cigarettes is above 2.5% and in many the figure rises to above 10%. (Relative Income Price is the percentage of annual per capita income, measured by per capita GDP, needed to purchase 100 packs of cheapest cigarettes.) Manufactured tobacco products are also quite expensive relative to average incomes in South Asia, where cigarette consumption is also low, as mentioned above. Curiously, the relative income price of cigarettes is relatively high in several Eastern European states, but it does not affect the rate of consumption there. Although aggregate data for Africa are not available, it does seem that cigarettes are becoming increasingly affordable. In Europe, on the other hand, cigarette affordability is declining.
Changes in cigarette affordability often affect cigarette consumption patterns over time, which, according to the Tobacco Atlas, correlate with levels of socio-economic development: in poorer countries cigarette consumption is growing, while in wealthier ones, such as France, Germany, the US, and Canada, it has been decreasing. Taxes, education, and smoke-free policies helped bring down cigarette consumption in Western Europe by 26% between 1990 and 2009. In the United States, the proportion of adults who smoke dropped from 42% in 1965 to 20.8% in 2006. In contrast, in the Middle East and Africa cigarette use has increased by nearly 60% in the past twenty years. “Among the 14 countries where 50% or more of men smoke,” the Tobacco Atlas informs us, “all but one country (Greece) are classified as low- or middle-income.” (The economic status of Greece has, of course, deteriorated of late). This increase in cigarette consumption in low- and middle-income countries leads to growth in tobacco-related deaths, which in turns burdens health-care systems and slows down economic growth. For example, China, which has catapulted into the ranks of the middle-income countries in recent years, consumed more than 38% of the world’s cigarettes in 2009, more than the other top four tobacco-using countries—Russia, United States, Indonesia, and Japan—combined. Tobacco use is estimated to result in 1.2 million deaths annually in China and is top cause of mortality in the country. The Tobacco Atlas states that tobacco-related deaths in China are expected to rise to 3.5 million annually by the year 2030.
China is also notable for its gender bias in tobacco consumption, with men smoking nearly all its cigarettes. One in two Chinese men smokes, but only 2% of women do. As the maps on the left show, the global patterns of smoking differ significantly by gender. Overall, more men than women smoke, by ratio of 4:1 (according to The Economist, “about 800m men smoke cigarettes, compared with fewer than 200m women”). The same pattern holds in virtually all individual countries. Besides China, the strongest male bias is found in Tunisia and Indonesia, where almost all smokers are men. More generally, the gender bias is particularly acute in developing countries: according to The Economist, “more than 80% of … male smokers are in low- and middle-income countries”. In the US, the gender bias is much less pronounced, with 24% of men smoking vs. 18% of women. Still, young women are among the few population groups whose smoking rates continue to increase in the United States.
Due to the gender bias in smoking rates, the figures for tobacco-related deaths also differ greatly between men and women.** Tobacco use is responsible for the greatest proportion of male deaths in Turkey and Kazakhstan, 38% and 35% respectively. Armenia, Poland, Belgium, Hungary, Bosnia and Herzegovina, the Maldives, Russia, and Belarus are also among the countries with high tobacco-related male mortality. As for female deaths due to tobacco use, the greatest proportion is found in the Maldives and—perhaps surprisingly—in the United States, at 25% and 23% respectively. More generally, the developed countries have the highest rates of female deaths due to tobacco, including Ireland, Denmark, Canada, 
United Kingdom, and Iceland.
While there are large differences in smoking rates among adults by gender, smoking rates among boys and girls (ages 13–15) vary minimally in many regions of the world. According to the Tobacco Atlas, smoking rates between boys and girls differ by less than five percentage points in almost half of the world’s countries. Worldwide, tobacco companies view youth smoking as an opportunity to secure new customers at a young age. Countries with the highest smoking rates among boys include Latvia, Lithuania, Belarus, Papua New Guinea, Malaysia, Tonga, Micronesia, Timor Leste, and Madagascar. Sadly, more girls than boys smoke in a number of countries, including Argentina, Uruguay, Cuba, Bulgaria, 
Slovenia, Sweden, and New Zealand.
My next post will examine the economic implications of tobacco use world-wide.
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* Another factor that affects the patterns of cigarette consumption is the tobacco marketing, to which I shall return in my next post.
** Tobacco-related “killers” include various types of cancer, respiratory and cardiovascular diseases, as well as certain digestive diseases, diabetes, and tuberculosis.
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