Smokeless tobacco of UzbekistanNasway:

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 pre-cancer 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

Source: Uzbekistan Health Examination Survey (UHES) 2002

Ever cigarette and nashway users in 2002 by age

7%

30%

43%

52%

59%55% 55%

49%

59%

41%

14%

35%

47%

52% 52%

42%

32% 34%

28%

38%

15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 Total

Ever users (%)

%ever smoked % ever naswhy

Nasway is more common among elderly women in Uzbekistan

Source: Uzbekistan Health Examination Survey (UHES) 2002

Ever cigarette and nashway users among women by age in 2002

0.7%

1.0%

2.0%

1.2%1.3%

1.8%

2.3%

0.4%

0.0%

0.3%

0.0%

0.3%

0.7%

2.0%

15-19 20-24 25-29 30-34 35-39 40-44 45-49

Age Group

Ever users (%)

ever smoked ever naswhy

Smokeless is more common among the less educated: Evidence from Vietnam

Smokeless tobacco and Cigarette Use among males in Vietnam by Education, 1998

05

1015202530354045

Less thanprimary

Primary Lowersecondary

Uppersecondary

Technical Universityand above

%

Cigarettes Pipe/chewing

Source: Vietnam Living Standard Survey 1998

But, in Uzbekistan, except high education groups, men use nasway as much as cigarettes

in all education levels

Source: Uzbekistan Health Examination Survey (UHES) 2002

Cigarette and Nashway Initiation by Education Level among Men in Uzbekistan 2002

30.0%

40.2%42.8%

46.4%

26.9%

42.7%

36.7%

27.7%

Primary/ middle secondary secondary/special higher

Education level

Initiation rate (%)

%ever smoked % ever naswhy

Smokeless is more common among the less educated women

Cigarette and Smokeless Tobacco Use among Women by Education in Vietnam, 1998

0

2

4

6

8

10

Less thanprimary

primary lowersecondary

uppoersecondary

techical Universityand above

Pre

vale

nce

rate

Cigarettes Pipe chewing

Vietnam Living Standard Survey, 1998

This is also the case in Uzbekistan.

Source: Uzbekistan Health Examination Survey (UHES) 2002

Cigarette and Nashway Initiation by Education Level among women in 2002

1.0%1.1%

2.0%

1.6%1.5%

0.3% 0.4% 0.3%

Primary/ middle secondary secondary/special higher

Education Level

Initiation rate (%)

ever smoked ever naswhy

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

0

5

10

15

20

25

30

35

40

Bottom Second Third Fourth Top

% o

f P

er

ca

pit

a e

xp

.

Cigarettes Pipe/chewing

Income Quintile

Source: Vietnam Living Standard Survey 1998

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

10%

34%

54%

14% 12%

0

10

20

30

40

50

60

Palau Meghalay 01 Uzbekistan (everusers)

Source: GYTS 1999-2001

Ghana,MalawiNigeria

USA

S. AfricaBahamas

ZimbabweDominica

13-19 yrs old

Source: Guindon & Boisclair. 2003. WHO

In the world todayIn the world today

48%48% of menof men

10%10% of women smokeof women smoke

Unless current smokers quit, smoking deaths will rise dramatically over the next 50 years

0

340

520

70

500

220

190

0

100

200

300

400

500

1950 2000 2025 2050

Year

Toba

cco

deat

hs (m

illio

n)

Baseline

If proportion ofyoung adultstaking up smokinghalves by 2020

If adultconsumptionhalves by 2020

Source: Peto and others, 1994; Peto, personal communication.

0 1000 2000 3000 4000 5000 6000 7000 8000

Occupational risk factors for injury

Unsafe health care injections

Vitamin A deficiency

Zinc deficiency

Urban air pollution

Iron deficiency

Indoor smoke from solid fuels

Unsafe water, sanitation, and hygiene

Alcohol

Physical inactivity

High Body Mass Index

Fruit and vegetable intake

Unsafe sex

Underweight

Cholesterol

Tobacco

Blood pressure

Tobacco was the second leading risk factor for NCD’s in Global Deaths in 2000Deaths in 2000 attributable to selected leading risk factors

Number of deaths (000s)

Mortality pattern in Uzbekistan, 2003

новообразования

7%

ischemic cardiac diseases

27%

diseases of blood circulation system

diseases of respiratory system

9%

diseases of digestive system

6%

some infectious and parasitory

diseases 3%

other 13%

external causes of death

7%

Ист: Комитет по статистике РУз

Number of deaths are higher for diseases that tobacco use may be one of the major causes

Mortality due to cancer of lips, oral cavity and throat by age groups in Uzbekistan, 2003г. (in absolute numbers)

2 21

1 12

7

31

4

10

6 68

21

10

26

17

26

4

38

17

34

12

36

20

16

12

1

63

4

0

5

10

15

20

25

30

35

40

Men Women Source: State Statistics Committee

Mortality by sex and age (%)

Women35%

Men65%

stomach cancer14%

female genital organs cancer

16%

other39%

cancer of lips, oral cavity and

throat 4%

cancer of trachea, bronhi,

lungs11%

cancer of esophagus

8%

cancer of kidneys and

liver 8%

Pattern of mortality due to cancer in Uzbekistan, 2003 ( %)

Women28%

Men72%

Cancer of lips, oral cavity Cancer of lips, oral cavity and throatand throat

Cancer of trachea, bronchi Cancer of trachea, bronchi and lungsand lungs

Source: State Statistics Committee, Uzbekistan

Prevalence of cancer due to tobacco is 2 times higher in men

Tobacco attributable Tobacco attributable deathsdeaths

The burden is moving to The burden is moving to developing developing countriescountries

Source: WHR 2002 & Peto et al. 1997Source: WHR 2002 & Peto et al. 1997

v tobacco kills 4.9 million persons each yeartobacco kills 4.9 million persons each yearv half of them live in developing countrieshalf of them live in developing countries

v the death toll is estimated to double in the 2020sthe death toll is estimated to double in the 2020sv 70% of these deaths will occur in developing countries70% of these deaths will occur in developing countries

v 1 in 2 long term smokers die because of their addiction1 in 2 long term smokers die because of their addictionv half of all long-term smokers will be killed by tobacco half of all long-term smokers will be killed by tobacco and half of them will die prematurely, losing 20–25 years and half of them will die prematurely, losing 20–25 years of lifeof life

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

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

High Income Upper MiddleIncome

Lower MiddleIncome

Low Income

Countries by income

Ave

rage

pric

e or

tax

per p

ack

(US$

)

0

10

20

30

40

50

60

70

80

Tax

as a

per

cent

age

of p

rice

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

0

500

1000

1500

2000

2500

Mill

ion

US$

government revenue

Industry revenue

Source: The tax burden on tobacco 2000, FTC report to Congress 2001

109.4

121.5

118

114

116

115.9

120

114

116.5

Sales

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$)

1999

(mil. US$)

% increase

Newspapers 2.8 3.3 18%

Point of sale 25.2 26 4%

Promotional allowances

14.9 30.7 106%

Coupons 11.0 24.2 121%

All other 5.9 7.3 22%

Source: FTC Report to Congress 2001

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.