Smokeless tobacco of Uzbekistan
Nasway:
PROCESSING: Sun- and heat-dried tobacco leaves, slaked lime, ash
from tree bark, and flavoring and coloring agents are mixed together.
Water is added and the mixture is rolled into balls
Smokeless tobacco is used in
many regions of the world
• America
– North America and Venezuela
• Europe– Sweden, UK
• Asia –
– Central Asia includes Nasway use
– East and
– Southeast Asia
• Middle-East – includes Nasway use
– Iran, Saudi Arabia, and Arab countries
• Africa- Sudan
Short and Long Term Health Effects of
Smokeless Tobacco Use
• Smokeless tobacco and cancer:
– 28 carcinogens have been identified in smokeless
tobacco in the US.
– Oral cancer, head and neck cancer, lung and pancreatic
cancer
• Smokeless tobacco and hard and soft on-or precancer oral lesions/conditions
– Leukoplakia, other mucosal lesions, recession,
gingivitis and periodontitis, dental caries, tooth
abrasion/attrition
Nasway is as common as cigarettes
among men in all age groups in
Uzbekistan
Ever cigarette and nashway users in 2002 by age
%ever smoked
Ever users (%)
% ever naswhy
59%
59%
52% 52%
52%
55%
55%
49%
47%
43%
42%
35%
41%
32%
30%
38%
34%
28%
14%
7%
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
Total
Source: Uzbekistan Health Examination Survey (UHES) 2002
Nasway is more common among elderly
women in Uzbekistan
Ever cigarette and nashway users among women by age in 2002
ever smoked
ever naswhy
2.3%
Ever users (%)
2.0%
2.0%
1.8%
1.3%
1.2%
1.0%
0.7%
0.7%
0.4%
0.3%
0.0%
15-19
20-24
0.3%
0.0%
25-29
30-34
35-39
40-44
45-49
Age Group
Source: Uzbekistan Health Examination Survey (UHES) 2002
Smokeless is more common among the
less educated: Evidence from Vietnam
%
Smokeless tobacco and Cigarette Use among males in
Vietnam by Education, 1998
Cigarettes
45
40
35
30
25
20
15
10
5
0
Less than
primary
Primary
Lower
secondary
Pipe/chewing
Upper
secondary
Source: Vietnam Living Standard Survey 1998
Technical
University
and above
But, in Uzbekistan, except high education
groups, men use nasway as much as cigarettes
in all education levels
Cigarette and Nashway Initiation by Education Level among Men
in Uzbekistan 2002
%ever smoked
% ever naswhy
46.4%
Initiation rate (%)
40.2%
42.7%
42.8%
36.7%
30.0%
27.7%
26.9%
Primary/ middle
secondary
secondary/special
higher
Education level
Source: Uzbekistan Health Examination Survey (UHES) 2002
Prevalence rate
Smokeless is more common among the
less educated women
10
8
6
4
2
0
Cigarette and Smokeless Tobacco Use among
Women by Education in Vietnam, 1998
Less than
primary
primary
lower
secondary
uppoer
secondary
Cigarettes
Vietnam Living Standard Survey, 1998
techical
Pipe chewing
University
and above
This is also the case in Uzbekistan.
Cigarette and Nashway Initiation by Education
Level among women in 2002
ever smoked
Initiation rate
(%)
ever naswhy
2.0%
1.6%
1.5%
1.0%
1.1%
0.4%
0.3%
Prim ary/ m iddle
secondary
secondary/special
0.3%
higher
Education Level
Source: Uzbekistan Health Examination Survey (UHES) 2002
As Income Increases, Smokeless Tobacco Use
Declines, Cigarette Smoking Increases: An evidence
from Vietnam
Tobacco Use by per Capita Expenditure by Quintiles, in 1998,
Vietnam
Cigarettes
% of Per capita exp.
40
Pipe/chewing
35
30
25
20
15
10
5
0
Bottom
Second
Third
Fourth
Income Quintile
Source: Vietnam Living Standard Survey 1998
Top
Significant youth prevalence rate for smokeless
tobacco in countries around the world
Smokeless tobacco leads to smoking
Smokeless tobacco prevalence among youth 13-15
years, 1999-2001
60
54%
Ghana,
Malawi
Nigeria
USA
50
40
34%
S. Africa
Bahamas
Zimbabwe
Dominica
30
20
14%
10
13-19
yrs old
0
Palau
Meghalay 01
Source: GYTS 1999-2001
Uzbekistan (ever
users)
12%
10%
In the world today
48% of men
10% of women smoke
Source: Guindon & Boisclair. 2003.
WHO
Tobacco deaths (million)
Unless current smokers quit, smoking deaths
will rise dramatically over the next 50 years
500
520
500
Baseline
340
If proportion of
young adults
taking up smoking
halves by 2020
400
300
220
200
190
100
If adult
consumption
halves by 2020
70
0 0
1950
2000
2025
2050
Year
Source: Peto and others, 1994; Peto, personal communication.
Tobacco was the second leading risk factor for NCD’s in Global Deaths in 2000
Deaths in 2000 attributable to selected leading risk factors
Blood pressure
Tobacco
Cholesterol
Underweight
Unsafe sex
Fruit and vegetable intake
High Body Mass Index
Physical inactivity
Alcohol
Unsafe water, sanitation, and hygiene
Indoor smoke from solid fuels
Iron deficiency
Urban air pollution
Zinc deficiency
Vitamin A deficiency
Unsafe health care injections
Number of deaths (000s)
Occupational risk factors for injury
0
1000
2000
3000
4000
5000
6000
7000
8000
Mortality pattern in Uzbekistan, 2003
Number of deaths are higher for diseases that tobacco use
may be one of the major causes
external causes of
death
7%
diseases of
digestive system
6%
other
13%
some infectious
and parasitory новообразовани
diseases
я
3%
7%
ischemic cardiac
diseases
27%
diseases of
respiratory system
9%
diseases of blood
circulation system
Ист: Комитет по статистике РУз
Mortality due to cancer of lips, oral cavity and throat by age groups in
Uzbekistan, 2003г. (in absolute numbers)
40
38
35
30
21
20
20
17
17
15
10
1
Men
2
3
4
12
10
12
6
4
3
1
1
60
-6
4
65
-6
9
70
-7
4
10 г
-1
4
15 г
-1
9
20 г
-2
4
25 г
-2
9
30 г
-3
4
35 г
-3
9
40 г
-4
4
г
45
-4
9
50
-5
4
55
-5
9
2 2 1
1
59
04
7
8
6 6
16
75
-7
9
80
85
-8
4
an
d
ov
er
10
0
34
26 26
25
5
36
Women
Source: State Statistics Committee
4
Pattern of mortality due to
cancer in Uzbekistan, 2003 ( %)
Mortality by sex and age (%)
Cancer of lips, oral cavity
and throat
Women
35%
cancer of lips,
oral cavity and cancer of
throat
esophagus
4%
8%
stomach cancer
14%
other
39%
female genital
organs cancer
16%
Men
65%
Cancer of trachea, bronchi
and lungs
cancer of
kidneys and
liver
cancer of 8%
trachea, bronhi,
lungs
11%
Women
28%
Men
72%
Prevalence of cancer due to tobacco is 2 times higher in men
Source: State Statistics Committee, Uzbekistan
Tobacco attributable deaths
The burden is moving to developing
countries
v
tobacco kills 4.9 million persons each year
v half of them live in developing countries
v
the death toll is estimated to double in the 2020s
v 70% of these deaths will occur in developing countries
v
1 in 2 long term smokers die because of their addiction
v half of all long-term smokers will be killed by tobacco
and half of them will die prematurely, losing 20–25 years
of life
Source: WHR 2002 & Peto et al. 1997
Which interventions are effective?
Measures to reduce demand
• Higher tobacco taxes
• Non-price measures: consumer information,
research, bans on tobacco advertising and
promotion, warning labels and restrictions
on public smoking
• Increased access to nicotine replacement
(NRT) and other cessation therapies
Youth are more sensitive to
price/tax increases
 Tax elasticity of snuff in 1985 for:
• 16-25 yr old males -0.31
• 25+ yr old males -0.13
Ohsfeldt, Boyle 1994, Ohsfeldt, Boyle, Capiluto 1997
 Tax elasticity of smokeless tobacco, 1992-94,
for 8th, 10th, and 12th grade students in US
was -0.07 and -0.04
Chaloupka, Tauras, Grossman 1997
Adults are also sensitive to tax
increases
• Tax elasticity : -0.15
– Snuff: -0.1 and –0.6
– Chewing: -0.13 and –0.6
• Economic substitutes
– Cross tax elasticity: 0.10
• snuff- cig: 0.13 and 0.6
• chewing-cig: 0.09 and 0.5
Source: Ohsfeldt and Boyle 1994, Ohsfeldt, Boyle, and Capilouto 1995
Very low price elasticity among youth and
adults requires substantial increase in taxes
to achieve a significant reduction
3.50
80
3.00
70
60
2.50
50
2.00
40
1.50
30
1.00
20
0.50
10
0.00
0
High Income
Upper Middle Lower Middle
Income
Income
Countries by income
Low Income
Tax as a percentage of price
Average price or tax per pack
(US$)
Average price in US$
Average tax in US$
Tax as a percentage of price
Effectiveness and Feasibility of Smokeless
tobacco taxes
Higher taxes work !!
But:
• Are substantial tax increases politically
feasible?
– Yes! Given the relatively small share of tax in the
price, a high tax increase would raise the prices a
modest amount only.
• Could smokeless tobacco taxes be collected
efficiently?
• Not certain that the cost of collecting taxes
would be lower than the extra tax revenues.
Revenues for government and the industry are
increasing despite reduction in consumption
US Industry and Government revenues from other
tobacco products 1985-1999
2500
121.5
Million US$
2000
Sales
120
118
1500
116.5
115.9
114
1000
116
114
government revenue
Industry revenue
500
19
85
19
86
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
0
Source: The tax burden on tobacco 2000, FTC report to Congress 2001
109.4
Would other policies work?
Yes!
• Raising minimum age from 18 to 19 would
reduce probability of consumption by 25%.
• Strong licensing provisions would reduce
the probability of consumption by 9%
• Ban on advertising could reduce
consumption
Changing Advertising Pattern
1998
(mil US$)
Newspapers 2.8
1999
(mil. US$)
3.3
% increase
Point of sale 25.2
26
4%
Promotional 14.9
allowances
Coupons
11.0
30.7
106%
24.2
121%
All other
7.3
22%
5.9
Source: FTC Report to Congress 2001
18%
Results
• Urgently need country-specific research evidence
to tailor TC policies in Uzbekistan
• Smokeless epidemic already hit the poorest of the
poor countries where TC action is weak.
• Comprehensive TC measures to reduce smoking
work for reducing smokeless tobacco, w/o
depending on tax increases alone.
• Strong measures should be taken to reduce youth
prevalence and access to smokeless tobacco
products.
Recommendations
• In countries where the smokeless tobacco already exist,
protect youth from smokeless tobacco use by introducing
comprehensive tobacco control measures
• Higher taxes supported by other tobacco control measures
prevent youth to start using smokeless tobacco, but taxes
should be increased substantially high to have significant
reduction in smokeless tobacco demand.
• Although smokeless tobacco does not generate as much
revenue as cigarettes, govt. will enjoy increasing revenues
when taxes increase while consumption decreases.